Author Question: Which of these interventions would take priority and should be included in a plan of care for a ... (Read 47 times)

sarasara · **on:** Jul 22, 2018

Which of these interventions would take priority and should be included in a plan of care for a patient who presents with pneumonia?

a. Observe the patient for decreased activity tolerance.
b. Assume that the patient is in pain and treat accordingly.
c. Maintain the temperature at 65 F.
d. Provide the patient ice chips as requested.

Question 2

The nurse has cared for a patient for several days. The patient is terminal and is very near death. The nurse notices the heart rate on the monitor decreasing and then the absence of a pattern.

The family is standing at the patient's bed, and when the nurse checks the patient and finds no pulse or blood pressure, the family begins sobbing and hugging each other. Some hold the patient's hand. The nurse is overwhelmed by the presence of grief and leaves the room to cry in the nurses' lounge. What is the nurse demonstrating? a. Task-oriented touch
b. Caring touch
c. Protective touch
d. None of the above

SamMuagrove · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A
Systemic infection causes more generalized symptoms than local infection. This type of infection can result in fever, fatigue, nausea and vomiting, and malaise. Be alert for changes in the patient's level of activity and responsiveness. Respiratory infection may result in a productive cough with purulent sputum, shortness of breath, and activity intolerance. Nurses do not assume but assess and communicate with the patient about pain, temperature, and ice chips. Asking these questions would not be a priority as much as assessing the patient and determining the effect that the systemic infection is having on the patient.

Answer to Question 2

C
When a nurse withdraws or distances herself or himself from a patient when the nurse is unable to tolerate suffering or needs to escape from a situation that is causing tension, the nurse is practicing a form of protective touch that is used to protect the nurse emotionally. Task-oriented touch is done when performing a task or procedure. Caring touch is a form of nonverbal communication that influences a patient's comfort and security, enhances self-esteem, and improves reality orientation.