The nurse caring for a toddler with tetralogy of Fallot observes the child squatting. Which action should the nurse take?

Wound healing post-arthroplasty requires optimal glycemic control and adequate nutritional intake to support tissue regeneration. In elderly patients with diabetes, microvascular dysfunction and impaired collagen synthesis can delay healing, even when granulation tissue is present. A comprehensive assessment must evaluate metabolic stability, dietary compliance, and psychosocial factors like anxiety, which can influence self-care behaviors and physiological recovery.

Rationale:

A. Assessing for anxiety is crucial as it can manifest as agoraphobia or post-operative fear of falling after hip surgery. Anxiety significantly impacts a patient's psychosocial well-being and their motivation to adhere to physical therapy or nutritional plans. Identifying emotional barriers allows for targeted interventions that support holistic recovery and functional independence.

B. Monitoring blood pressure at home provides data on cardiovascular stability outside the clinical setting. Since the client has diabetes, she is at higher risk for autonomic neuropathy or hypertension, which can affect peripheral perfusion to the surgical site. Tracking these trends helps the nurse determine if vascular health is contributing to slow wound healing.

C. Caffeine consumption should be evaluated because it acts as a stimulant and a mild diuretic. Excessive intake can lead to dehydration or interfere with sleep patterns, both of which are detrimental to the metabolic processes required for wound repair. It also provides insight into the client's overall dietary habits and potential nutritional gaps.

D. Verifying the blood sugar log is essential to assess the management of type 2 diabetes. Persistent hyperglycemia impairs leukocyte function and increases the risk of surgical site infections, even if the wound currently looks clean. Correlating these values with the laboratory reference range ensures the metformin dose is effectively maintaining euglycemia.

E. Obtaining a 24-hour diet recall allows the nurse to quantify protein and caloric intake necessary for surgical recovery. Adequate protein is the building block for fibroblast activity and tissue synthesis in the proliferative phase of healing. This specific question helps confirm the suspicion that the client is not meeting the increased metabolic demands of recovery.

An internal disaster in a healthcare facility requires the immediate activation of the Hospital Incident Command System (HICS). When critical infrastructure, such as power or emergency generators, fails, the primary objective is to maintain environmental stability and prevent chaos. The charge nurse must ensure that all personnel and patients are accounted for and that movement throughout the facility is restricted to prevent injuries during periods of low visibility or equipment failure.

Rationale:

A. Telling clients to stay in their rooms is the first and most vital instruction. During a total power failure, hallways may be dark, and electronic security systems may be compromised. Keeping clients in their rooms ensures their physical safety, prevents falls, and allows the nursing staff to perform an accurate headcount and assessment of immediate needs within a controlled environment.

B. Offering to assist in the intensive care unit (ICU) is a well-intentioned but disorganized response. While ventilator-dependent clients are at the highest risk during power failures, the reallocation of staff must be coordinated through the central command center. UAPs should not leave their assigned units until the charge nurse has established that their current clients are stable and supervised.

C. Shutting all doors "in case a fire erupts" is a specific protocol for a Fire Emergency (Code Red), not necessarily a general power failure. While keeping doors closed can be part of a safety check, the immediate priority during a generator malfunction is client accountability and communication. Fire protocols should only be prioritized if there is an actual threat of smoke or flames.

D. Going to the emergency department (ED) to complete tasks is inappropriate during an internal disaster. The ED will likely be managing its own surge of critical issues. Staff must remain on their assigned units to ensure the safety of the 350 beds already occupied. Straying from one's post without direct orders from the Incident Commander disrupts the organized disaster response plan.