A veteran is hospitalized after surgical amputation of both lower extremities owing to injuries sustained during military service. Which type of loss will the nurse focus the plan of care on for this patient?

Choice A reason: Knowing involves understanding the patient’s experiences and needs, not actively forming a care plan together. Enabling focuses on empowering the patient through collaboration, as seen here. Assuming knowing risks underemphasizing the patient’s active role, potentially limiting empowerment and self-efficacy critical for colostomy care acceptance and management.

Choice B reason: Doing for involves performing tasks for the patient, not collaborating on a plan, as with enabling. The nurse’s joint planning empowers the patient to manage colostomy care. Assuming doing for overlooks patient autonomy, risking dependency and reduced confidence in self-care, critical for long-term colostomy management and adaptation.

Choice C reason: Enabling, per Swanson’s caring theory, involves facilitating the patient’s capacity to manage their care through collaboration, as seen in forming a colostomy care plan together. This empowers the patient, fostering confidence and acceptance. Enabling supports self-efficacy, critical for psychological adjustment and practical management of a new colostomy, enhancing patient outcomes.

Choice D reason: Maintaining belief sustains hope and values but doesn’t involve collaborative planning, unlike enabling. The nurse’s focus is empowering practical colostomy care, not spiritual support. Assuming maintaining belief misaligns with the action, potentially neglecting the patient’s need for active involvement in learning and adapting to colostomy self-care.

Choice A reason: Respirations of 22 and heart rate of 66 suggest arousal or light sleep, not deep NREM sleep, which features slower, regular breathing (12-16 breaths/min) and lower heart rate. This indicates discomfort or instability, not comfortable sleep. Assuming this reflects NREM sleep risks overlooking signs of inadequate rest or stress in ICU patients.

Choice B reason: Mumbling to self indicates partial arousal or REM sleep, not NREM sleep, which is characterized by minimal movement and stable vitals. This suggests discomfort or neurological disturbance. Assuming NREM sleep misidentifies the sleep stage, potentially missing interventions to promote deeper, restorative sleep critical for ICU patient recovery.

Choice C reason: Tossing in bed with respirations of 18 and heart rate of 80 indicates restlessness or light sleep, not deep NREM sleep, which involves calm, slow vitals. This suggests discomfort or pain. Assuming NREM sleep risks neglecting interventions like pain management, critical for ensuring restorative sleep in ICU settings.

Choice D reason: Eyes closed, lying quietly, with respirations of 12 and heart rate of 60 indicate deep NREM sleep, characterized by slow, regular breathing and low heart rate, reflecting parasympathetic dominance. This confirms comfortable, restorative sleep, critical for healing in ICU patients, guiding nurses to maintain conditions supporting this optimal sleep state.