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 superior vena cava is responsible for returning deoxygenated blood from the upper body to the heart and is not directly involved in myocardial ischemia.
B. The carotid artery supplies blood to the brain and is not the primary focus in the context of myocardial infarction.
C. The pulmonary artery carries deoxygenated blood from the heart to the lungs and is not involved in coronary circulation.
D. The coronary arteries supply blood to the heart muscle itself. Ischemia during a myocardial infarction occurs when these arteries are blocked or narrowed, leading to a lack of blood flow and oxygen to the heart tissue.
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.