The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Choice A reason: Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Since the wound involves subcutaneous tissue, it exceeds the criteria for Stage 2.

Choice B reason: Stage 1 pressure injuries are characterized by non-blanchable erythema of intact skin. While the skin is still intact, it may appear red and not lighten when pressed. Given the description of a wound involving subcutaneous tissue, Stage 1 is not appropriate.

Choice C reason: Stage 3 pressure injuries involve full-thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, but the depth of tissue damage varies by anatomical location. This aligns with the wound involving subcutaneous tissue.

Choice D reason: Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. While the wound described involves subcutaneous tissue, there is no mention of deeper tissue involvement, excluding Stage 4 classification.

Choice A reason: Type 2 diabetes mellitus, while a serious chronic condition, does not directly predispose patients to delirium. Diabetes primarily impacts the body's ability to regulate blood glucose levels, leading to complications such as cardiovascular disease, neuropathy, and nephropathy. However, it is not directly linked to the acute cognitive disturbances seen in delirium unless it leads to severe metabolic derangements, which is less common.

Choice B reason: Alcohol abuse is a significant risk factor for the development of delirium, especially in ICU patients. Chronic alcohol use can lead to a condition known as delirium tremens (DTs) during withdrawal, characterized by severe agitation, confusion, hallucinations, and autonomic hyperactivity. Patients with a history of alcohol abuse may have altered brain chemistry and neurotransmitter imbalances that predispose them to delirium when stressed by illness or surgery. Moreover, alcohol abuse can lead to liver dysfunction, nutritional deficiencies (particularly thiamine), and other systemic issues that further exacerbate the risk.

Choice C reason: Anxiety can exacerbate stress and discomfort in a patient but is not a primary causative factor for delirium. Anxiety may contribute to an increased sense of fear or confusion, especially in an ICU setting. However, it does not cause the profound disruption in cognitive function, attention, and awareness that characterizes delirium.

Choice D reason: Impaired communication might be a consequence or symptom seen in patients with delirium, but it is not a root cause. Patients with pre-existing communication difficulties might struggle more to express symptoms or needs, which could complicate care, but it does not inherently lead to the onset of delirium. Effective communication strategies and aids can help manage these challenges but do not address the underlying neurological changes seen in delirium.