A nurse is preparing to complete a neurological assessment on a newly admitted patient. Which action should the nurse prioritize first?

A. "I've given her some medication; please report to me whether it seems to have relieved her pain within an hour or so.": NAP are not responsible for evaluating the effectiveness of analgesics, as this requires clinical judgment and assessment skills within the nurse’s scope of practice. Subjective impressions may lead to inaccurate conclusions about pain control.

B. "Be sure to keep the room temperature high and the TV on at all times.": Environmental measures alone are not sufficient for pain management and do not address the primary responsibility of NAP in monitoring patient responses. Maintaining comfort is important, but instructions must be clinically relevant to pain assessment and communication.

C. "Be sure to tell me if you assess an increase in pain, grimacing, or any unusual behavior.": NAP can observe and report nonverbal signs of pain or changes in behavior, which are critical for ongoing assessment. Prompt reporting enables the nurse to intervene appropriately, such as administering medication or implementing additional comfort measures.

D. "Let me know at least 30 minutes before you transport her so I can administer her analgesics.": While coordinating analgesic administration with planned activities is important, this instruction focuses on timing rather than the NAP’s role in monitoring or reporting pain. NAP should observe and communicate changes in pain rather than determine when to medicate.

A. Full thickness skin loss of the subcutaneous tissue: Stage 3 pressure injuries involve full-thickness loss of the skin extending through the dermis into the subcutaneous tissue. The subcutaneous fat may be visible, and the depth of the wound varies by anatomical location, making this a defining characteristic of Stage 3 injuries.

B. A deep purplish area is noted: A deep purplish or maroon area is more characteristic of a suspected deep tissue injury rather than a Stage 3 pressure injury. These injuries involve underlying tissue damage beneath intact or minimally broken skin and may not involve full-thickness loss of subcutaneous tissue at this stage.

C. A shallow wound bed is present: Shallow wounds are typical of Stage 2 pressure injuries, which involve partial-thickness loss of dermis and present as open, superficial ulcers. Stage 3 wounds are deeper and extend through the full thickness of the skin into subcutaneous tissue.

D. No visible bone, tendon, and ligaments are noted: In Stage 3 pressure injuries, the bone, tendon, or muscle is not exposed. The injury extends into subcutaneous tissue but stops short of deeper structures, distinguishing it from Stage 4 pressure injuries.

E. Visible bone, tendon, and ligaments are noted: Exposure of bone, tendon, or ligaments indicates a Stage 4 pressure injury, which involves full-thickness tissue loss with damage extending into underlying structures. This finding exceeds the depth seen in Stage 3 injuries.