A nurse is educating a terminally ill patient about declining resuscitation in a living will.
The patient asks, “What would happen if I arrived at the emergency department and I had difficulty breathing?” Which of the following responses should the nurse make?

Choice A rationale

Granulation tissue covering the wound bed is a positive sign of wound healing. Granulation tissue is a key component of the wound healing process, typically forming during the proliferation phase. It consists of new connective tissue and tiny blood vessels that develop in the wound bed as part of the body’s response to injury. Therefore, the presence of granulation tissue covering the wound bed indicates an improvement in the patient’s condition.

Choice B rationale

Slight erythema at the wound edges could be a sign of inflammation or infection. Erythema, or redness of the skin, is often associated with inflammation or infection. While it can be a normal part of the healing process, persistent or increasing erythema could indicate a problem such as infection or irritation. Therefore, slight erythema at the wound edges does not necessarily indicate an improvement in the patient’s condition.

Choice C rationale

The surrounding tissue being warm to touch could be a sign of inflammation or infection. When skin feels hot to the touch, it often means that the body’s temperature is hotter than normal. This can happen due to an infection or an illness, but it can also be caused by an

environmental situation that increases body temperature. Therefore, the surrounding tissue being warm to touch does not necessarily indicate an improvement in the patient’s condition.

Choice D rationale

The patient reporting pain as a 2 on a scale from 0 to 10 could indicate that the patient’s pain is minor. On a pain scale, a score of 2 usually indicates minor pain. However, pain is a subjective experience and can vary greatly among individuals. Therefore, while a lower pain score generally suggests less severe pain, it does not necessarily indicate an improvement in the patient’s overall condition.

The correct answers are Choices A, B, and C.

Choice A rationale: Passive range-of-motion exercises should be performed more frequently than once each day to maintain joint mobility, prevent contractures, and stimulate circulation. Performing them only once daily is inadequate for a client with paraplegia who is immobile.

Choice B rationale: Nonblanchable erythema is a sign of a stage 1 pressure ulcer, indicating that the skin is at risk of further breakdown and infection. Immediate intervention is required to prevent progression to more severe pressure injuries.

Choice C rationale: Plantar flexion contractures can lead to significant long-term disability and complications, such as difficulty in ambulation and pain. These contractures require intervention through more frequent range-of-motion exercises, splinting, or physical therapy to prevent worsening.

Choice D rationale: Pedal pulses that are 2+ bilaterally are within normal limits and indicate adequate peripheral circulation. This finding does not require intervention.