A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?

Place the patient in the room farthest from the nurses’ station.

Ask the patient “Would you like a newspaper to read?”

Offer the patient a back rub.

Hang a “Do not disturb” sign on patient’s door.

Answer and Explanation

The Correct Answer is B

Choice A reason: Placing the patient farthest from the nurses’ station increases isolation, worsening sensory deprivation. Bed rest already limits stimuli, and distance reduces interaction with staff, exacerbating disorientation or loneliness. This action contradicts the need to provide sensory stimulation, making it an incorrect choice.

Choice B reason: Asking if the patient wants a newspaper provides visual and cognitive stimulation, counteracting sensory deprivation from bed rest. Reading engages the mind, reducing boredom and disorientation. This action aligns with promoting sensory input, making it an appropriate intervention to maintain mental engagement and well-being.

Choice C reason: Offering a back rub provides tactile stimulation, which is beneficial, but sensory deprivation primarily affects cognitive and perceptual functions. Reading a newspaper better addresses visual and intellectual needs, more directly countering the effects of limited environmental stimuli, making this a less optimal choice.

Choice D reason: Hanging a “Do not disturb” sign reduces interactions, increasing sensory deprivation. Bed rest patients need regular engagement to prevent disorientation or depression. This action isolates the patient further, contradicting the goal of providing sensory stimulation, making it an incorrect intervention.

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Correct Answer is C

Explanation

Choice A reason: Health promotion involves teaching lifestyle changes, not physical touch or emotional support, as seen here. Presence focuses on being with the patient empathetically. Assuming health promotion misaligns with the action, risking neglect of the patient’s emotional and spiritual needs, critical for comfort in terminal illness care settings.

Choice B reason: Offering transcendence involves fostering spiritual meaning, not physical touch or presence. The nurse’s hand-touching establishes emotional connection, not existential exploration. Assuming transcendence overlooks the relational aspect of presence, potentially missing the patient’s immediate need for comfort and connection in the context of terminal illness care.

Choice C reason: Establishing presence involves being physically and emotionally available, as shown by sitting and touching the patient’s hand. This empathetic connection, rooted in Watson’s caring theory, fosters comfort and trust, critical for terminally ill patients. Presence supports emotional well-being, ensuring holistic care and dignity in end-of-life situations.

Choice D reason: Doing for involves performing tasks like bathing, not emotional support through touch. The nurse’s action establishes presence, not task-oriented care. Assuming doing for risks misinterpreting the action, potentially neglecting the patient’s need for empathetic connection, essential for psychological comfort in terminal illness care.

A. Maturational loss B. Situational loss C. Perceived loss D. Uncomplicated loss

Correct Answer is B

Explanation

Choice A reason: Maturational loss occurs with normal developmental transitions, like aging or menopause. Amputation from military injuries is an unexpected event, not a developmental milestone. This type does not apply to the veteran’s sudden, trauma-related loss, making it incorrect for the care plan focus.

Choice B reason: Situational loss results from unpredictable events, like amputation due to military injuries. This loss impacts the veteran’s mobility, identity, and lifestyle, requiring targeted interventions for grief, adaptation, and rehabilitation. The nurse’s care plan should focus on addressing this situational loss to support emotional and physical recovery.

Choice C reason: Perceived loss is subjective, like loss of self-esteem, but amputation is a tangible, objective loss of limbs. While emotional impacts exist, the primary loss is physical and situational. This type is less specific to the veteran’s experience, making it an incorrect focus for the care plan.

Choice D reason: Uncomplicated loss refers to normal grief without complications, not a specific type of loss. Amputation is a complex situational loss with physical and psychological impacts. This term does not capture the nature of the veteran’s experience, making it inappropriate for the care plan focus.

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A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?

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A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?