A nurse is educating a newly licensed nurse about ethical principles. Which of the following situations is an example of beneficence?

A nurse keeps a promise to a client not to tell their family about their diagnosis.

A nurse provides therapeutic touch by holding a dying patient's hand.

A nurse involves a client in making decisions about their care.

A nurse tells the truth about forgetting to perform a procedure for a client.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is B

Explanation

The correct answer is choice B. Necrotic subcutaneous tissue.

Choice A rationale:

Partial-thickness skin loss (Choice A) is characteristic of a stage II pressure ulcer, not a stage III ulcer. A stage II pressure ulcer involves the loss of the epidermis and possibly the dermis, resulting in a shallow open ulcer with a red-pink wound bed.

Choice B rationale:

Necrotic subcutaneous tissue is a manifestation of a stage III pressure ulcer. A stage III ulcer involves full-thickness skin loss where subcutaneous fat may be visible, but exposed bone or muscle is not yet present. Necrotic tissue in the wound bed indicates a more advanced level of tissue damage and the need for appropriate wound care to promote healing.

Choice C rationale:

Blood-filled blisters (Choice C) are not specific to pressure ulcers and are more commonly associated with friction or shear forces. These blisters are not indicative of a stage III pressure ulcer, which involves visible full-thickness tissue loss.

Choice D rationale:

Exposed bone (Choice D) is a characteristic of a stage IV pressure ulcer, not a stage III ulcer. A stage IV ulcer involves extensive tissue loss with exposure of muscle, tendon, or bone. This represents a severe level of tissue damage and requires intensive wound care and management.

A. Visual observation for nonverbal signs of pain. B. Vital sign measurement. C. The client's self-report of pain severity. D. The nature and invasiveness of the surgical procedure.

Correct Answer is C

Explanation

Choice A rationale:

Visual observation for nonverbal signs of pain can be useful, especially in patients who are unable to communicate verbally. However, this method is not as accurate or reliable as obtaining the client's self-report of pain severity, which directly allows the patient to express their experience.

Choice B rationale:

Vital sign measurement, such as heart rate, blood pressure, and respiratory rate, can provide indirect information about a patient's pain level. However, vital signs can be influenced by various factors, including anxiety or other physiological responses. They may not always accurately reflect the intensity of pain and are not as specific as the client's self-report.

Choice C rationale:

The client's self-report of pain severity is the most reliable and accurate method for determining the intensity of pain. Pain is a subjective experience, and the client's self-report is crucial for effective pain management. Pain scales, such as numeric rating scales or visual analog scales, allow clients to describe their pain intensity in a standardized way.

Choice D rationale:

The nature and invasiveness of the surgical procedure are relevant factors to consider in understanding a patient's potential pain experience. However, this information alone is not sufficient for determining the current intensity of the client's pain. Pain levels can vary among individuals undergoing the same procedure due to differences in pain tolerance and perception.

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A nurse is educating a newly licensed nurse about ethical principles. Which of the following situations is an example of beneficence?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer is B

Explanation

A nurse is caring for a postoperative client who is awake, alert, and oriented. Which of the following methods should the nurse use as part of her pain management interventions to determine the intensity of the client's pain?

Correct Answer is C

Explanation

A nurse is teaching a client's spouse about how to obtain a blood pressure reading. Which of the following actions by the spouse indicates a need for further instruction?

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A nurse caring for a client who has an infected wound removes a dressing saturated with blood and purulent drainage. How should the nurse dispose of the dressing material?

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