A nurse is caring for a client admitted with a superficial bacterial skin infection involving the lower left leg. The client reports the area started as a small red, crusted lesion that has gradually spread over the past three days. On assessment, the nurse notes erythema extending beyond the wound margins, warmth, and areas of honey-colored crusting. The client's temperature is 38.3°C and heart rate is 102 bpm. Which assessment finding most concerns the nurse because it suggests the infection may be spreading beyond the skin surface?
- Honey-colored crusting on the wound surface
- Red streaking extending proximally up the leg from the wound site
- Mild pruritus reported by the client at the wound edges
- Erythema confined to the area immediately surrounding the lesion