The nurse is assessing an older adult’s orientation. Which question is most appropriate?

Choice A reason: Limited ability to reposition is a major risk factor for pressure injuries, as immobility increases pressure on bony prominences, reducing blood flow and causing tissue ischemia. This leads to skin breakdown, particularly in bedridden patients, making it a critical factor in pressure ulcer development.

Choice B reason: Requiring stand-by assistance for activities of daily living (ADLs) indicates some mobility, as the patient can perform tasks with supervision. This does not inherently increase pressure injury risk, unlike immobility or moisture, making it the least relevant risk factor among the choices.

Choice C reason: Poor nutritional state is a risk factor for pressure injuries, as malnutrition impairs skin integrity and wound healing. Deficiencies in protein or vitamins reduce tissue resilience, increasing susceptibility to pressure-induced damage, particularly in elderly or debilitated patients.

Choice D reason: Moisture from incontinence, wound drainage, or perspiration softens skin, increasing friction and shear forces, which heighten pressure injury risk. It compromises skin barrier function, promoting maceration and ulceration, making it a significant contributor to pressure ulcer formation.

Choice A reason: Head protrusions are not expected in older adults; they may indicate abnormal growths or trauma, requiring investigation. Thinning hair is a normal aging change. Assuming protrusions are expected risks missing serious conditions like tumors, delaying diagnosis and treatment critical for ensuring safety in elderly patients.

Choice B reason: Asymmetry of facial features is not a normal aging variation; it may suggest stroke or Bell’s palsy, needing urgent evaluation. Thinning hair is expected due to hormonal changes. Assuming asymmetry is normal risks overlooking neurological issues, delaying interventions critical for older adults’ health and functional outcomes.

Choice C reason: Thinning hair is an expected aging variation, resulting from reduced hair follicle activity and hormonal changes in older adults. Unlike vertigo or asymmetry, it’s benign and doesn’t require intervention unless cosmetic. Recognizing this ensures accurate assessment, focusing on abnormal findings like vertigo that need medical attention in elderly patients.

Choice D reason: Vertigo is not an expected aging variation; it may indicate inner ear disorders or neurological issues, requiring evaluation. Thinning hair is a normal change. Assuming vertigo is expected risks delaying diagnosis of treatable conditions like BPPV, compromising safety and quality of life in older adults.