The nurse is caring for a patient who refuses to bathe in the morning. When asked why, the patient says, "I always bathe in the evening." Which action by the nurse is best?
Explain the importance of maintaining morning hygiene practices.
Tell the patient that daily morning baths are the "normal" routine.
Cancel hygiene for the day and attempt again in the morning.
Defer the bath until evening and pass on the information to the next shift.
The Correct Answer is D
A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.
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Correct Answer is C
Explanation
A. Discontinuing pain medication may not be appropriate, as it can lead to inadequate pain management for the patient. Pain management is crucial for terminally ill patients.
B. While abdominal massage may help relieve mild constipation, it is not a reliable primary intervention for more severe constipation caused by medication.
C. Laxatives are commonly prescribed for constipation related to pain medication and are an effective method to promote bowel movements, making this the best choice.
D. Administering enemas twice daily can be excessive and may cause discomfort or lead to dependency, making this option less favorable than using laxatives.
Correct Answer is C
Explanation
A. Notifying the health care provider is not the most appropriate first action, as parental consent is needed.
B. Contacting the United Network for Organ Sharing is premature without consent from the parents.
C. Since the patient is a minor, parental consent is generally required for organ donation. Instructing the patient to discuss this desire with their parents is essential for obtaining legal consent.
D. Preparing the organ donation form is also premature, as minors cannot legally consent without parental approval.