A nurse is caring for an 77 year-old. Which sensory change will the nurse identify as normal during the assessment?

A. one drop to both eyes four times a day: Administering the drops four times daily exceeds the prescribed frequency. Overmedication can increase the risk of local irritation, systemic absorption, or toxicity, and does not align with the provider’s intended dosing schedule. Accurate adherence to the order is essential for safe and effective therapy.

B. one drop to both eyes as needed: "As needed" (PRN) dosing allows for patient- or symptom-driven administration, which differs from a scheduled prescription. The order specifies a fixed schedule (tid), so administering PRN would not ensure therapeutic effectiveness or consistency of drug levels in the eyes.

C. one drop to both eyes three times a day: "Tid" stands for three times a day, and administering one drop to each eye at this frequency follows the provider’s instructions. Proper timing ensures consistent therapeutic drug levels, maximizes efficacy, and minimizes complications or missed doses.

D. one drop to both eyes two times a day: Administering the drops twice daily would underdose the patient, potentially reducing the treatment’s effectiveness. It does not meet the prescribed "tid" schedule, which is necessary for achieving the intended clinical outcome.

A. Stage 1 pressure injury: Stage 1 pressure injuries are characterized by intact skin with localized nonblanchable redness, typically over bony prominences. The presence of a large, open wound with granulation tissue and irregular borders on the lower leg does not fit the criteria for a Stage 1 injury.

B. Venous stasis ulcer: Venous stasis ulcers are commonly located on the medial lower leg near the ankle and are often shallow with irregular borders. The wound bed contains red granulation tissue and has areas of slough. Surrounding skin shows brownish discoloration (hemosiderin staining) due to chronic venous insufficiency and red blood cell leakage as seen in this patient.

C. Arterial ulcer: Arterial ulcers generally occur on the distal lower extremities, such as the toes or lateral malleolus, and have well-defined borders with a pale, dry wound bed. They are often painful and associated with diminished pulses, which differs from the characteristics of the wound observed here.

D. Diabetic ulcer: Diabetic ulcers most commonly appear on pressure points of the foot, such as the plantar surface or under the metatarsal heads, and are usually neuropathic in origin. The medial lower leg location and the features of venous insufficiency make a diabetic ulcer less likely.