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Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed.

Asking the patient what pain-relief methods, pharmacological and nonpharmacological approach have worked best in the past?

Administering pain-relief medication according to what was given last shift.

Offering pain-relief medications based on the providers orders.

Answer and Explanation

The Correct Answer is B

A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed. Pain is subjective and should always be believed and assessed rather than dismissed based on procedure type. This does not demonstrate critical thinking.

B. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked best in the past. This approach assesses the patient’s individual experience and applies personalized care, which is a hallmark of critical thinking.

C. Administering pain-relief medication according to what was given last shift. Pain levels fluctuate, and medication effectiveness must be reassessed each time. Simply repeating the previous shift’s orders does not involve critical thinking.

D. Offering pain-relief medications based on the provider’s orders. While following orders is necessary, critical thinking involves assessing the patient’s pain level and determining the most appropriate intervention rather than blindly administering medication.

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Correct Answer is C

Explanation

A. Disposable measuring tape: While measuring the wound is important, assessing the wound’s color and depth should be the first step to determine staging.

B. Cotton-tipped applicator: A cotton-tipped applicator is useful for assessing undermining or tunneling, but it is not the first step in staging a pressure ulcer.

C. Natural light: In darkly pigmented skin, color changes may not be obvious under artificial lighting. Using natural light helps the nurse detect early signs of skin breakdown.

D. Sterile gloves: Gloves are necessary for infection control, but they do not assist in staging the ulcer. First, assess the wound using natural light.

A. Stage I Pressure Ulcer B. Stage III Pressure Ulcer C. Healing Stage III Pressure Ulcer D. Healing Stage II Pressure Ulcer

Correct Answer is C

Explanation

A. Stage I Pressure Ulcer: A Stage III pressure ulcer does not regress to a Stage I as it heals. It retains its original staging classification.

B. Stage III Pressure Ulcer: While the ulcer was originally Stage III, documenting it this way without specifying healing progress does not accurately reflect its current condition.

C. Healing Stage III Pressure Ulcer: Pressure ulcers are documented at their worst stage, even as they heal. The correct terminology includes "healing" to show improvement.

D. Healing Stage II Pressure Ulcer: A Stage III ulcer does not become a Stage II ulcer as it heals; instead, it is called a healing Stage III pressure ulcer.

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Which patient scenario of a surgical patient in pain is most indicative of critical thinking?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which item should the nurse use first to assist in staging an ulcer on the heel of a darkly pigmented skin patient?

Correct Answer is C

Explanation

The wound care nurse is monitoring a patient with a stage III pressure ulcer whose wound presents with healthy tissue. How should the nurse document this in the patient's medical record?

Correct Answer is C

Explanation

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