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 B
Explanation
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.
Correct Answer is ["A","B","C","D"]
Explanation
A. Asking about travel outside the United States helps identify potential exposure to infections that are more prevalent in certain areas.
B. Assessing handwashing techniques is crucial, as proper hand hygiene is a fundamental way to prevent infections.
C. Understanding the patient's perception of infection risk in their home environment can highlight potential areas for intervention.
D. Knowing the signs and symptoms of infection allows the nurse to evaluate the patient’s awareness and ability to recognize early signs of infection.
E. While mobility can affect overall health, it is not directly related to assessing the risk of infection.
F. Knowing who runs errands may provide context for the patient's support system, but it does not directly assess infection risk.