A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?
Anxiety over illness
Increased metabolic demands
Decreased drive to breathe
Infection destroying lung tissues
The Correct Answer is B
A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.
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Correct Answer is D
Explanation
A. Grief evaluation refers to assessing the grief process rather than actively engaging in supportive dialogue, which is not the primary focus of the nurse's action.
B. Pain-management techniques would not apply directly to this context, as the discussion centers on emotional support rather than physical pain.
C. Palliative care encompasses a broader approach to managing patients with serious illnesses but does not specifically address the emotional support provided in this situation.
D. The nurse's action of discussing the child's life and death helps the parents express their grief and memories, thereby facilitating normal mourning, making this the most appropriate principle demonstrated.
Correct Answer is D
Explanation
A. The nursing diagnosis "Impaired physical mobility" is appropriate and does not need revision.
B. There is no collaborative problem mentioned in the statement that requires revision.
C. The defining characteristic "patient's inability to ambulate" accurately reflects the patient's current condition and does not need changes.
D. The etiology "related to tibial fracture" should be revised to reflect a more precise causal factor that can be addressed by nursing interventions. A more appropriate etiology could specify the limitation in mobility rather than just stating the fracture.