Upon skin inspection of an older adult, the coccyx wound is noted to be intact, reddened, and non-blanchable. What is the best way to document the nurse's assessment finding?

Correct Answer: A

Rationale: The correct way to document the nurse's assessment finding of an intact, reddened, and non-blanchable coccyx wound in an older adult is as a stage I pressure injury. In stage I pressure injuries, the skin is intact but shows non-blanchable redness, indicating potential tissue damage. This finding aligns with the description provided in the question. Stage II pressure injuries involve partial-thickness skin loss, which is not the case here. Stage III injuries involve full-thickness tissue loss without bone, and stage IV injuries involve full-thickness tissue loss with exposed bone or muscle, both of which are more severe than the presented findings. Therefore, the best way to document this assessment finding is as a stage I pressure injury.

Correct Answer: C

Rationale: In this scenario, the correct ethical principle emphasized by the nurse's actions to prevent falls using bed alarms and assisting with mobility is nonmaleficence. Nonmaleficence is the principle of doing no harm or preventing harm to patients. By taking proactive measures to prevent falls, the nurse is actively working to avoid harm or injury to the patient, aligning with the ethical principle of nonmaleficence. Autonomy (Option A) refers to respecting a patient's right to make their own decisions, which is not the primary focus in this situation where patient safety is the priority. Privacy (Option B) pertains to protecting a patient's personal information and confidentiality, which is not directly related to fall prevention measures. Justice (Option D) involves fairness and equal treatment, which is also not the primary ethical principle being highlighted here. In an educational context, understanding and applying ethical principles in nursing practice is crucial for providing safe, effective, and patient-centered care. Nurses must consider ethical principles like nonmaleficence when making decisions to promote patient well-being and prevent harm. By reinforcing the importance of ethical principles in scenarios like fall prevention, nursing students can develop a strong ethical framework to guide their practice and decision-making in real-world healthcare settings.

Correct Answer: B

Rationale: The correct answer is option B: "The alignment of EBP with the core principles of the nursing profession is not contingent upon the incorporation of nursing theory into research." This statement reflects a misunderstanding of the critical role that nursing theory plays in research and evidence-based practice (EBP). It is essential to clarify this misconception to ensure that nursing students grasp the significance of integrating nursing theory into research. Option A is incorrect because nursing theories do indeed guide research by providing a framework for understanding phenomena and guiding practice. Option C is incorrect as the integration of nursing theory in research is crucial for ensuring that research findings are relevant and applicable to nursing practice. Option D is incorrect because understanding how nursing theory informs research priorities is essential to advancing the evidence base and promoting evidence-based practice in nursing. Without the incorporation of nursing theory into research, the evidence generated may lack the depth and specificity needed to address the complexities of nursing practice. In an educational context, it is crucial to emphasize to nursing students that nursing theory is not an optional component in research but rather a foundational element that enriches the evidence base of the profession and strengthens the quality of nursing practice. Understanding this connection is vital for students to become effective, evidence-based practitioners.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Sudden onset of continuous epigastric and back pain. This symptom is indicative of acute pancreatitis due to the inflammation of the pancreas that often presents with severe abdominal pain radiating to the back. This pain is typically described as constant and severe, making it a key assessment finding for this condition. Option A) Blood pressure above normal range is not a specific indicator of acute pancreatitis. While acute pancreatitis can lead to complications such as hypotension due to dehydration or shock, high blood pressure is not a typical finding associated with this condition. Option B) Hyperactive bowel sounds are not directly related to pancreatitis. Pancreatitis is more commonly associated with decreased or absent bowel sounds due to the inflammatory process affecting the gastrointestinal tract. Option D) Presence of crackles in both lung fields is not a typical assessment finding in acute pancreatitis. Crackles in the lung fields are more indicative of conditions such as heart failure or pneumonia, which are not directly related to pancreatitis. In an educational context, understanding the specific assessment findings associated with different medical conditions is crucial for nursing students. By recognizing the unique symptoms of acute pancreatitis, students can provide timely and appropriate care to patients experiencing this condition, leading to better outcomes and patient satisfaction.

Correct Answer: A

Rationale: The correct answer to the question "The scope of Nursing practice is legally defined by: A) The nursing practice act" is A) The nursing practice act. This is because the nursing practice act is a set of laws established by each state that governs the scope of nursing practice within that state. It outlines the legal boundaries within which nurses can practice, defining the responsibilities and limitations of nursing practice. This act is essential for ensuring patient safety, maintaining professional standards, and protecting the public. Option B) Professional nursing organizations do play a role in setting standards and guidelines for nursing practice, but they do not legally define the scope of nursing practice. While they provide valuable resources and support for nurses, they do not have the authority to establish legal boundaries for nursing practice. Option C) Hospital policy and procedure manuals vary from one institution to another and are not legally binding documents that define the scope of nursing practice. They provide guidelines specific to the institution's policies and procedures but do not have the authority to establish legal boundaries for nursing practice. Option D) Physicians in the employing institution do not have the authority to legally define the scope of nursing practice. While collaboration with physicians is an essential aspect of nursing practice, physicians do not have the jurisdiction to set legal boundaries for nursing practice. In an educational context, understanding the legal framework that governs nursing practice is crucial for nursing students. It ensures that they are aware of their professional responsibilities, limitations, and the legal implications of their practice. Knowledge of the nursing practice act helps nurses provide safe and effective care within the legal boundaries of their practice.