The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?
All cultures value cleanliness with the same degree of importance.
Patients who appear unkempt place little importance on hygiene practices.
The patient’s illness may require teaching of new hygiene practices.
Personal preferences determine hygiene practices and are unchangeable.
The Correct Answer is C
A. Cultural values regarding cleanliness vary, so it is inaccurate to assume uniform standards.
B. Judging the patient as placing "little importance" on hygiene due to appearance can lead to biases and does not consider the patient’s routine.
C. Diabetes may necessitate changes in hygiene practices, especially regarding foot care, to prevent complications. Education on optimal hygiene practices is essential for health management in diabetic patients.
D. While personal preferences influence hygiene, they can be adapted with appropriate education and guidance when necessary for health reasons.
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Correct Answer is C
Explanation
A. Competent nurses have typically worked in a specific area for 2-3 years, developing an understanding of patient care specific to that field.
B. Proficient nurses have advanced understanding and experience, allowing them to see care situations as whole parts rather than in separate steps.
C. In a new specialty area, the nurse is considered a novice, as they lack experience and expertise in obstetrics despite previous nursing experience.
D. Advanced beginners have some experience but still need support; however, this would apply only if the nurse had some previous obstetric experience.
Correct Answer is A
Explanation
A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.