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","F"]
Explanation
A. Applying knowledge of disease processes is essential in preventing the spread of infections and understanding transmission routes.
B. Proper disposal of supplies is crucial in minimizing the risk of cross-contamination and infection spread.
C. Checking the negative-pressure system is critical to ensure it functions properly to contain airborne pathogens.
D. Hand hygiene is a key practice in preventing infection and should be performed before and after patient contact in both scenarios.
E. This statement is misleading; while some precautions may overlap, there are specific differences that must be addressed in interventions for airborne versus contact precautions.
F. It is important for patients in airborne precautions to wear a mask during transportation to prevent the spread of infectious particles.
Correct Answer is C
Explanation
A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.