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The nurse is evaluating the body alignment of a patient in the sitting position. Which observation by the nurse will indicate a normal finding?

A.

The arms hang comfortably at the sides.

B.

The edge of the seat is in contact with the popliteal space.

C.

Both feet are supported on the floor with ankles flexed.

D.

The body weight is directly on the buttocks only.

Answer and Explanation

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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Explanation

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D. A chest tube is typically used to remove air or fluid from the pleural space, not for the treatment of atelectasis, which is often managed with respiratory therapies.

Correct Answer is A

Explanation

A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.

B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.

C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.

D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.

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