A nurse is performing tracheostomy care for a patient and plans to remove copious secretions. What actions should the nurse take?

 

 

Choice A rationale

Spending time with the patient is a therapeutic nursing approach when caring for a patient hospitalized for the treatment of severe depression. This approach shows the patient that they

are not alone and that their feelings are important. It can help build trust and rapport, which are essential for effective therapeutic communication and intervention.

Choice B rationale

Offering the patient choices of activities can be beneficial as it can provide a sense of control and improve mood. However, this approach should be used judiciously as the patient’s energy levels and interest in activities may be low due to depression.

Choice C rationale

Establishing a therapeutic relationship with the patient is an important aspect of care. However, this is a broad approach and involves more than just spending time with the patient. It includes building trust, maintaining confidentiality, and providing empathetic and nonjudgmental care.

Choice D rationale

Exploring the truth of the patient’s statements can be part of cognitive behavioral therapy (CBT), a common treatment for depression. However, this is usually done by a trained therapist and not by a nurse providing general care.

The correct answer is Choice A

Choice A rationale: Iron 38 mcg/dL is below the normal range for children (50-120 mcg/dL). Low iron levels can indicate iron deficiency anemia, which requires medical evaluation and intervention to prevent complications such as developmental delays and decreased immunity.

Choice B rationale: RBC 4.9 million/mm is within the normal range for children (4.0-5.5 million/mm). This value does not indicate any abnormalities and does not require reporting to the provider. RBC count helps in assessing the overall red blood cell health and oxygen-carrying capacity.

Choice C rationale: WBC 10,000 cells/mm is within the normal range for children (5,000-10,000 cells/mm). This value is considered normal and does not indicate an infection or other condition needing immediate attention. WBC count is critical for evaluating the immune system's response to infection.

Choice D rationale: Lead 2 mcg/dL is within the acceptable range for children. The Centers for Disease Control and Prevention (CDC) considers lead levels less than 5 mcg/dL to be acceptable. Lead exposure can harm children's development, but this level does not necessitate immediate reporting