You are assessing a client and note a pressure injury on the client’s sacrum. The lesion is a deep depression below the level of skin and into the muscle and there appears to be a spot where the bone is visible. What stage of the pressure injury would you document for this wound?

Choice A reason: Assessment in the nursing process involves collecting subjective and objective data via interviews, physical exams, and observations to inform clinical judgments. This foundational step identifies patient needs, guiding subsequent planning. Accurate data collection ensures comprehensive care, preventing oversight of critical health issues and supporting effective diagnosis and intervention in clinical practice.

Choice B reason: Using problem-solving to prioritize outcomes and develop interventions describes the planning step, not assessment. Assessment focuses on data collection, not goal-setting. Assuming this misaligns with the nursing process, risking premature intervention without thorough data, which could lead to ineffective care plans or missed health issues in patient management.

Choice C reason: Assessing goal effectiveness and adjusting interventions pertains to the evaluation step, not assessment. Assessment gathers data to identify needs, not evaluate outcomes. Misidentifying this risks skipping data collection, leading to incomplete assessments and inappropriate interventions, compromising patient safety and care quality in the nursing process.

Choice D reason: Using clinical judgment to formulate problems is part of diagnosis, not assessment. Assessment collects raw data, while diagnosis analyzes it to identify issues. Assuming this conflates steps, risking incomplete data collection, which could result in inaccurate diagnoses and ineffective care plans, undermining the systematic approach of the nursing process.

Choice A reason: Cyanosis, indicating hypoxia, is not typical in alcohol use disorder with weight gain and abdominal tightness, which suggest liver issues like ascites causing jaundice. Assuming cyanosis risks misdiagnosis, delaying liver assessment or treatment, critical for managing complications like cirrhosis or portal hypertension in patients with chronic alcohol use.

Choice B reason: Erythema (redness) is unrelated to alcohol-related abdominal tightness and weight gain, which indicate liver dysfunction, often presenting with jaundice. Misdiagnosing erythema risks overlooking hepatic issues, delaying interventions like diuretics for ascites, essential for managing liver complications and improving outcomes in alcohol use disorder patients.

Choice C reason: Appearing normal is unlikely with alcohol use disorder causing weight gain and abdominal tightness, typically from ascites or liver damage, presenting as jaundice. Assuming normal risks missing serious liver pathology, delaying diagnosis and treatment, critical for preventing progression of cirrhosis or liver failure in affected patients.

Choice D reason: Jaundice, yellowing of skin, is likely in alcohol use disorder with abdominal tightness and weight gain, indicating liver dysfunction (e.g., cirrhosis or alcoholic hepatitis) causing ascites. Recognizing this guides urgent liver evaluation and treatments like abstinence or diuretics, critical for managing complications and improving survival in chronic alcohol users.