A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?

Anxiety over illness

Increased metabolic demands

Decreased drive to breathe

Infection destroying lung tissues

Answer and Explanation

The Correct Answer is B

A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.

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Correct Answer is ["A","B","C","D"]

Explanation

A. A patient with an indwelling catheter requires regular perineal care to prevent infection due to increased risk from the catheter.
B. Urinary and fecal incontinence increase the risk of skin breakdown and infection, necessitating frequent perineal care.
C. Surgical dressings in the rectal and genital areas require perineal care to maintain hygiene and prevent wound contamination.
D. Bariatric patients often need regular perineal care due to skin folds and increased risk of moisture-related skin breakdown.
E. A circumcised, ambulatory male typically has a lower risk of infection and may not require as frequent perineal care unless other factors are present.

A. Realizing that the patient's only goal is relief of the anxiety. B. Looking at how worry influences the patient's ability to function. C. Helping the patient realize that there is little hope of relief from anxiety. D. Focusing on finding quick remedies for the anxiety.

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.

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A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patients will the nurse determine are in most need of regular perineal care? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

The patient is admitted with a diagnosis of chronic anxiety. Which action is most appropriate for the nurse to take when providing holistic care?

Correct Answer is B

Explanation

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