The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?
The arms hang comfortably at the sides.
The edge of the seat is in contact with the popliteal space.
Both feet are supported on the floor with ankles flexed.
The body weight is directly on the buttocks only.
The Correct Answer is A
A. This observation indicates proper body alignment as the arms hanging comfortably at the sides suggest relaxation and good posture.
B. The edge of the seat should not be in contact with the popliteal space; there should be a small gap to prevent pressure and improve circulation.
C. While the feet should be supported on the floor, they should be flat rather than flexed at the ankles for optimal alignment.
D. The body weight should be distributed between the buttocks and thighs, not just on the buttocks, to promote comfort and good posture.
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Correct Answer is ["A","B","C","D"]
Explanation
A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.
Correct Answer is D
Explanation
A. While hospice care is appropriate for those with terminal illnesses, the criteria are more specifically defined by life expectancy rather than just the diagnosis itself.
B. Although pain management is a significant aspect of hospice care, the criteria for eligibility focus on life expectancy rather than need for pain management alone.
C. Completion of an advance directive is encouraged but not a specific criterion for hospice care; patients can receive hospice services without having an advance directive in place.
D. Hospice care is typically designated for patients who are expected to live less than 6 months, focusing on providing comfort and support in the final stages of life.