A terminally ill patient expresses concerns about leaving their young children behind. What is the best action the nurse can take to provide patient-centered care?

Suggest that the patient focus on their medical condition rather than family concerns.

Encourage the patient to discuss their feelings openly and involve the family in the care process

Avoid discussing emotional concerns to prevent upsetting the patient further,

Refer the patient to pastoral care without addressing their com concerns directly

Answer and Explanation

The Correct Answer is B

A. Suggest that the patient focus on their medical condition rather than family concerns: Redirecting the patient away from their emotional concerns dismisses their feelings and does not provide holistic, patient-centered care. Emotional support is essential in terminal illness.

B. Encourage the patient to discuss their feelings openly and involve the family in the care process: Facilitating open discussion allows the patient to express fears and emotions, strengthens family communication, and provides psychological support. This approach respects the patient’s values and promotes holistic care.

C. Avoid discussing emotional concerns to prevent upsetting the patient further: Avoidance can increase anxiety and isolation. Addressing emotional concerns directly, with empathy, supports coping and provides comfort during end-of-life care.

D. Refer the patient to pastoral care without addressing their concerns directly: Referral can be beneficial, but it should complement—not replace—the nurse’s direct engagement. The nurse should first acknowledge and validate the patient’s feelings before involving additional resources.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. The injury may present as a blister, shallow ulcer, or abrasion. Since the skin in this case is intact, it does not meet Stage II criteria.

B. Stage IV: Stage IV pressure injuries are full-thickness tissue losses with exposed bone, tendon, or muscle. This severe stage is accompanied by extensive tissue damage, which is not present in this scenario.

C. Stage III: Stage III injuries involve full-thickness skin loss with damage or necrosis of subcutaneous tissue. The injury may extend down to, but not through, underlying fascia. The intact skin observed here does not qualify as Stage III.

D. Stage I: Stage I pressure injuries are characterized by non-blanchable erythema of intact skin, usually over a bony prominence. This is the earliest stage and indicates localized tissue damage without loss of skin integrity, matching the scenario described.

A. Stage II B. Stage I C. Stage III D. Stage IV

Correct Answer is C

Explanation

A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. There may be a shallow open ulcer, blister, or abrasion, but subcutaneous fat is not visible. The described wound is deeper, so it does not fit Stage II criteria.

B. Stage I: Stage I pressure injuries are characterized by intact skin with non-blanchable erythema. There is no tissue loss or ulceration, making this stage inconsistent with the wound described.

C. Stage III: Stage III pressure injuries involve full-thickness skin loss with visible subcutaneous fat. The wound extends below the dermis into the subcutaneous tissue, creating a deep depression. This description matches the characteristics of a Stage III pressure injury.

D. Stage IV: Stage IV pressure injuries involve full-thickness skin and tissue loss with exposed bone, tendon, or muscle. Since the description mentions subcutaneous fat but no bone, tendon, or muscle exposure, Stage IV is not appropriate.

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A terminally ill patient expresses concerns about leaving their young children behind. What is the best action the nurse can take to provide patient-centered care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a patient, you observe non-blanchable redness over a bony prominence with intact skin. What is the most appropriate classification for this pressure injury?

Correct Answer is D

Explanation

A patient has a pressure injury on the sacrum with visible subcutaneous fat and a deep depression below the skin level. What stage of pressure injury would you document?

Correct Answer is C

Explanation

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A terminally ill patient expresses concerns about leaving their young children behind. What is the best action the nurse can take to provide patient-centered care?