A nurse is admitting an elderly client into a unit. During the initial assessment, the nurse notes an erythematous wound with partial-thickness skin loss. The wound does not contain slough and is located on the patient's right heel. How will the nurse stage this pressure ulcer?
Stage I Pressure ulcer.
Stage II Pressure ulcer.
Stage IV Pressure ulcer.
Stage II Pressure ulcer.
The Correct Answer is B
Choice A rationale:
Stage I Pressure ulcer - This choice is not correct because a Stage I pressure ulcer is characterized by intact skin with non-blanchable redness over a bony prominence. There is no partial-thickness skin loss at this stage.
Choice B rationale:
Stage II Pressure ulcer - This is the correct choice. A Stage II pressure ulcer involves partial-thickness skin loss that presents as a shallow open ulcer with a red-pink wound bed, without slough. It may also manifest as an intact or open/ruptured serum-filled blister.
Choice C rationale:
Stage IV Pressure ulcer - This choice is not correct because a Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. There is no mention of such extensive tissue loss in the given scenario.
Choice D rationale:
Stage II Pressure ulcer - This choice is a duplicate of Choice B and is not correct for the reasons stated above.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Keeping a promise to a client not to tell their family about their diagnosis is an example of fidelity, respecting confidentiality and maintaining trust. However, it does not directly reflect the ethical principle of beneficence, which focuses on actions that promote the patient's well-being and best interests.
Choice B rationale:
Providing therapeutic touch to a dying patient by holding their hand is an example of beneficence. This action demonstrates compassion, emotional support, and comfort to the patient in a critical and vulnerable time. It promotes the patient's well-being by addressing their emotional and psychological needs.
Choice C rationale:
Involving a client in making decisions about their care is an example of respecting their autonomy and practicing shared decision-making. While this action is important and aligns with the principle of autonomy, it is not a direct example of beneficence, which centers on actively doing good for the patient.
Choice D rationale:
Telling the truth about forgetting to perform a procedure for a client is an example of honesty and integrity, which are essential ethical principles in nursing. However, it does not directly relate to beneficence, which emphasizes actions that actively contribute to the patient's well-being and benefit.
Correct Answer is D
Explanation
Choice A rationale:
Asking the client's closest kin to convince him to stop fasting due to his injuries is not an appropriate action. Respecting the client's religious beliefs and practices is crucial, and attempting to persuade the client to stop fasting would infringe upon their autonomy and cultural values.
Choice B rationale:
Encouraging the client to stop fasting goes against respecting the client's religious observance and autonomy. The nurse should prioritize culturally competent care and support the client in their religious practices, while also ensuring their nutritional needs are met.
Choice C rationale:
Calling dietary to reschedule the client's meals might seem like a reasonable action, but it does not address the client's religious needs or their wound healing process. Ramadan fasting is an important religious practice, and the nurse should find a way to accommodate the client's fasting while also ensuring appropriate nutritional support.
Choice D rationale:
Starting enteral tube feedings if the client refuses to take food orally is the correct action. Beneficence, a principle of ethical nursing care, emphasizes promoting the well-being of the patient. In this case, the nurse should prioritize the client's wound healing by ensuring they receive necessary nutrition through enteral feeding while still respecting their fasting during Ramadan.
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