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. An increase in heart rate does not directly affect hemoglobin levels; this option is incorrect.
B. A higher heart rate decreases diastolic filling time, as there is less time for the heart to fill between beats, which can lead to reduced stroke volume.
C. An increased heart rate does not inherently increase stroke volume; in fact, at very high rates, stroke volume can decrease due to reduced filling time.
D. The significant increase in heart rate to 164 beats/min can lead to decreased cardiac output due to compromised diastolic filling and reduced stroke volume.
Correct Answer is D
Explanation
A. Explaining the importance of morning hygiene may overlook the patient's established routine and could create resistance.
B. Stating that morning baths are the "normal" routine does not acknowledge the patient's preferences, potentially causing the patient to feel invalidated.
C. Canceling hygiene for the day disregards the patient's needs and preferred routine.
D. Deferring the bath until evening respects the patient’s routine and preference, promoting patient-centered care and improving comfort and compliance with hygiene practices.