The nurse caring for a terminally ill patient sits down and lightly touches the patient’s hand. Which technique is the nurse using?

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.

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.