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 D
Explanation
A. The belief tool typically involves assessing specific beliefs but does not encompass the broader scope of spiritual well-being.
B. The FICA assessment tool focuses on Faith, Importance, Community, and Address, but it is not characterized by a lengthy questionnaire.
C. The Hope scale assesses a patient's sense of hope but does not specifically address spirituality in depth.
D. The spiritual well-being scale includes multiple questions that explore various aspects of spirituality, including the relationship with God and life purpose, making it the most appropriate choice for this assessment.
Correct Answer is B
Explanation
A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.