The patient must stay in bed for a bed change. Which actions will the nurse implement? (Select all that apply.)
Turn clean pillowcase inside out over the hand holding it.
Keep soiled linen close to uniform.
Apply sterile gloves.
Make a modified mitered corner with sheet, blanket, and spread.
Advise patient will feel a lump when rolling over.
Correct Answer : A,D
A. Turning the clean pillowcase inside out over the hand holding it helps avoid contamination and allows easy application.
B. Soiled linens should be kept away from the nurse's uniform to prevent cross-contamination; hence, this is incorrect.
C. Sterile gloves are not required for bed-making; clean gloves may be used when handling soiled linens.
D. A modified mitered corner keeps the bed neat and helps secure the sheet, blanket, and spread.
E. Advising the patient of a lump when rolling over is not necessary for bed making, as the goal is to provide comfort without lumps.
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Correct Answer is D
Explanation
A. The belief tool typically involves assessing specific beliefs but does not encompass the broader scope of spiritual well-being.
B. The FICA assessment tool focuses on Faith, Importance, Community, and Address, but it is not characterized by a lengthy questionnaire.
C. The Hope scale assesses a patient's sense of hope but does not specifically address spirituality in depth.
D. The spiritual well-being scale includes multiple questions that explore various aspects of spirituality, including the relationship with God and life purpose, making it the most appropriate choice for this assessment.
Correct Answer is B
Explanation
A. While anxiety relief is important, holistic care encompasses the patient's overall well-being and not just the alleviation of symptoms.
B. Understanding how anxiety impacts the patient's daily functioning allows for a more comprehensive approach to care, addressing both psychological and practical concerns.
C. It is inappropriate to suggest to the patient that there is little hope for relief, as this can negatively affect their mental health.
D. Focusing solely on quick fixes does not address the underlying issues of chronic anxiety and may not lead to long-term improvements.