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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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View Related questions

Correct Answer is B

Explanation

A. Increasing activity level may be unrealistic for a patient on strict bed rest due to a pelvic fracture.

B. Repositioning every 2 hours is a realistic and achievable goal for a patient on bed rest to prevent complications such as pressure ulcers and maintain circulation.

C. Using a walker for ambulation may not be feasible immediately after a pelvic fracture.

D. Transferring with a sliding board may not be safe or appropriate in the early stages post-injury, especially if bed rest is required.

Correct Answer is D

Explanation

A. Assuming that both have the same spiritual beliefs can lead to misunderstandings; individual beliefs can vary significantly even within the same affiliation.

B. Skipping the spiritual belief assessment is inappropriate as it is essential to understand the patient's unique beliefs and values to provide holistic care.

C. While a formal assessment tool can be helpful, it is not mandatory; what’s most important is engaging in a dialogue about the patient’s beliefs rather than strictly following a formal method.

D. It is crucial for the nurse to respect the patient's unique spiritual beliefs and not impose personal values, making this the most appropriate action to support the patient spiritually.

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