While caring for an unconscious patient, the nurse discovers a stage 2 pressure ulcer on the patient’s heel. During care of the ulcer, what is the nurse’s understanding of the patient’s perception of pain?

Correct Answer: B

Rationale: The correct answer is B) The area should be treated as a painful lesion, using gentle cleansing and dressing. In the context of an unconscious patient with a stage 2 pressure ulcer, it is crucial for the nurse to understand that even though the patient may not be able to verbalize pain, the presence of a pressure ulcer indicates tissue damage that can still elicit a pain response. Therefore, the nurse should treat the area as a painful lesion by using gentle cleansing and appropriate dressing to promote healing while minimizing discomfort for the patient. Option A is incorrect because the absence of a behavioral response does not necessarily mean the patient is not experiencing pain. Pain perception is subjective and can vary among individuals, especially in patients who are unconscious or unable to communicate. Option C is incorrect because assuming that the patient cannot perceive pain due to being unconscious is a dangerous assumption. Pain perception can still occur even in unconscious patients, and aggressive scrubbing can further damage the fragile tissue of a pressure ulcer. Option D is incorrect because not all nociceptive stimuli necessarily lead to the perception of pain. Pain is a complex phenomenon influenced by various factors beyond just the transmission of signals to the brain. This scenario highlights the importance of a comprehensive understanding of pain perception and management in patients, especially those who are unable to communicate their discomfort. Nurses must approach care with empathy, knowledge, and a patient-centered mindset to ensure optimal outcomes and comfort for all patients.

Correct Answer: A

Rationale: In this scenario, the correct answer is Option A: Assess their understanding of what hospice care services are. The first step for the nurse is to gather information about the family's knowledge and beliefs regarding hospice care. This is crucial as it allows the nurse to address any misconceptions, provide accurate information, and facilitate an open discussion about end-of-life care options. Option B is incorrect because asking how they will care for the patient without hospice care assumes that the family is capable or willing to provide appropriate care, which may not always be the case in a complex situation like terminal pancreatic cancer. Option C is incorrect because while it is important to involve the patient and family in decision-making, attempting to change their minds without first understanding their perspectives can lead to conflict and resistance. Option D is incorrect and culturally inappropriate as it assumes all Hispanic families have the same preferences for caring for their loved ones. It is essential to avoid stereotyping and instead focus on individual beliefs and needs. Educationally, this question highlights the importance of cultural competence, effective communication, and patient/family-centered care in end-of-life situations. Nurses must engage in open dialogue, respect diverse beliefs, and provide accurate information to support families in making informed decisions that align with their values and preferences.

Correct Answer: C

Rationale: In this case, the correct answer is C) Advance care planning. Advance care planning is a process that involves making decisions about the medical care a person would want to receive if they become unable to make their own decisions. Directives to physicians, durable power of attorney for health care, and medical power of attorney are legal documents that are typically included in advance care planning. Option A) Natural death acts and B) Allow natural death are related to end-of-life care but do not specifically include directives to physicians or powers of attorney. Option D) Do Not Resuscitate order is a specific medical order related to resuscitation preferences but does not encompass the broader scope of medical decision-making covered by advance care planning. Understanding legal documents related to healthcare decision-making is crucial for healthcare professionals to ensure they respect patients' autonomy and provide care that aligns with their wishes. By knowing the components of advance care planning, healthcare providers can better support patients in making informed decisions about their treatment preferences and end-of-life care.

Correct Answer: D

Rationale: The correct answer is D) Overuse and dependence on a substance that negatively affects functioning. Substance abuse refers to the excessive use of a substance such as alcohol or drugs, leading to negative consequences on an individual's physical, mental, and social well-being. This definition encompasses both the misuse of substances and the resulting impact on an individual's ability to function in their daily life. Option A) A compulsive need to experience pleasure, while related to addiction, does not fully capture the harmful consequences and impact on functioning that define substance abuse. Option B) Behavior associated with maintaining an addiction is too broad and does not specifically address the negative effects on functioning that characterize substance abuse. Option C) Absence of a substance will cause withdrawal symptoms is more aligned with physical dependence rather than the broader concept of substance abuse, which includes the impact on overall functioning. Educationally, understanding the definition of substance abuse is crucial for healthcare professionals, especially those in pharmacology, as it helps in recognizing, assessing, and intervening in cases of substance abuse to provide appropriate care and support to individuals struggling with addiction. It also highlights the importance of considering the holistic effects of substance abuse beyond just the physical aspects.

Correct Answer: B

Rationale: In this scenario, Mary is displaying symptoms of mania, which can be induced by antidepressants like fluoxetine in individuals with bipolar disorder. The correct answer is to start a mood stabilizer because Mary's symptoms suggest a switch from depression to a manic state. Mood stabilizers are essential in managing manic episodes to prevent potential harm and stabilize mood fluctuations. Option A is incorrect because continuing the selective serotonin reuptake inhibitor can exacerbate Mary's manic symptoms. Switching to a tricyclic antidepressant (Option C) is not recommended as they can also induce manic episodes. Adding a monoamine oxidase inhibitor (Option D) is not the best choice as it can worsen mania. Educationally, this question highlights the importance of recognizing and managing manic symptoms induced by antidepressants, especially in individuals with bipolar disorder. Understanding the need for mood stabilizers in such cases is crucial for safe and effective patient care.