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Jumping in to provide patient comfort, while well-intentioned, implies reactive or task-oriented actions rather than the intentional, empathetic engagement of presence. Presence involves being emotionally available, fostering trust and connection, not just addressing immediate physical needs. This choice risks misrepresenting the holistic, relational aspect of presence critical for patient and family support.

Being there without an identified goal does not fully capture presence, which is purposeful in fostering emotional and spiritual support. Presence involves intentional closeness and caring, not aimless attendance. This choice underestimates the nurse’s role in creating a therapeutic environment, potentially diminishing the impact of presence on patient and family well-being.

Focusing on tasks prioritizes technical care over emotional connection, contrary to presence, which emphasizes being with the patient holistically. Task-oriented care may address physical needs but neglects the relational support central to presence. This choice misaligns with the concept, risking a purely functional approach that overlooks emotional and spiritual care needs.

Asking when the patient wakes up provides limited insight into PTSD. While sleep timing may indicate disturbances, it doesn’t address specific PTSD symptoms like intrusive memories or hyperarousal. This question is less urgent, risking delayed identification of PTSD, which requires targeted psychological assessment to guide therapy and medication for trauma-related nightmares.

Describing phobias is irrelevant to PTSD assessment, as phobias are distinct anxiety disorders. PTSD involves trauma-specific symptoms like flashbacks, not generalized fears. This question misdirects focus from trauma-related sleep issues, potentially delaying PTSD diagnosis and appropriate interventions like trauma-focused therapy, leaving the patient’s nightmares and distress unaddressed.

Asking about chest pain assesses physical symptoms unrelated to PTSD’s psychological profile, which includes nightmares and intrusive thoughts. While chest pain could indicate anxiety or cardiac issues, it’s not a priority for suspected PTSD. This question risks overlooking trauma-related symptoms, delaying psychological evaluation and support critical for the patient’s mental health recovery.

Asking the family about normal behavior provides subjective context but lacks standardized cognitive assessment. Cognitive function requires objective tools like the MMSE to evaluate memory, orientation, and attention. Relying solely on family input risks missing subtle deficits, delaying diagnosis of conditions like dementia or delirium critical for patient management.

Asking for name, location, and month tests orientation, a component of cognitive assessment, but is too limited. The MMSE offers a comprehensive evaluation of memory, language, and visuospatial skills. This narrow approach risks overlooking broader cognitive impairments, potentially missing early dementia or other neurological conditions requiring targeted interventions.

The HHIE-S assesses hearing impairment, not cognitive function. Hearing loss may affect communication but isn’t a direct cognitive measure. Using this tool for cognition misdirects assessment, risking failure to identify cognitive deficits like memory loss, delaying diagnosis and management of conditions such as Alzheimer’s disease or acute confusional states.

Immediate intubation is premature without first reversing opioid-induced respiratory depression with naloxone. Morphine’s rapid onset of lethargy and shallow breathing (7 breaths/min) indicates overdose, reversible by naloxone. Intubation is invasive and reserved for non-responsive cases, risking unnecessary complications when reversal is feasible, delaying targeted treatment in this acute scenario.

Observing for opioid tolerance is inappropriate in this acute situation. Lethargy and shallow breathing indicate overdose, not tolerance, requiring immediate naloxone. Monitoring tolerance delays critical intervention, risking prolonged hypoxia, brain damage, or death, especially in an elderly patient with increased opioid sensitivity post-surgery, where respiratory depression is life-threatening.

Assessing pain level is irrelevant when the patient exhibits opioid overdose symptoms like lethargy and respiratory depression. Pain assessment is secondary to reversing life-threatening respiratory compromise with naloxone. Delaying intervention for pain evaluation risks patient deterioration, as immediate action is needed to restore breathing and stabilize the patient post-morphine administration.

Culture and ethnicity influence pain perception but are not easily modifiable. They shape attitudes toward pain expression, not pain itself. Focusing on these risks overlooking modifiable factors like anxiety, which directly amplify pain. Interventions targeting modifiable psychological factors are more effective in reducing pain intensity and improving patient coping strategies.

Previous pain experiences and cognitive abilities are relatively fixed, shaping pain perception but not easily altered. Modifiable factors like anxiety have a greater immediate impact on pain. Focusing on these risks delaying interventions like relaxation techniques, which directly reduce pain amplification, improving outcomes in acute or chronic pain management.

Age and gender are non-modifiable factors influencing pain sensitivity but not amenable to change. Anxiety and fear, which exacerbate pain through stress responses, are modifiable and more relevant for intervention. Prioritizing age or gender misdirects focus, delaying strategies like cognitive therapy that effectively mitigate pain in clinical settings.

Maintaining belief, while part of Watson’s model, focuses on sustaining patient values, not directly fostering hope. Instilling faith-hope is a specific carative factor addressing spiritual and emotional needs, more relevant for holistic care. Prioritizing belief risks underemphasizing hope’s role in motivating patients, especially in challenging health scenarios requiring emotional resilience.

Maintaining ethics is not a specific carative factor in Watson’s model, though ethical care is implicit. Instilling faith-hope directly supports patients’ emotional and spiritual needs, central to holistic nursing. Focusing on ethics risks missing Watson’s emphasis on caring processes like hope, which enhance patient trust and healing in clinical practice.

Instilling values is not a carative factor in Watson’s model, which emphasizes factors like faith-hope for holistic care. Values are patient-specific and not nurse-instilled. Prioritizing this misaligns with Watson’s framework, potentially neglecting emotional support like hope, critical for fostering patient resilience and well-being in health challenges.

Short naps (15-20 minutes) are recommended for narcolepsy to manage excessive daytime sleepiness without disrupting nighttime sleep. This aligns with evidence-based management, improving alertness. No intervention is needed, as this practice supports symptom control, enhancing daily function and reducing sleep attacks in narcolepsy patients.

Taking antidepressants, like SSRIs or SNRIs, is standard for narcolepsy to manage cataplexy or sleep disturbances. This is appropriate and requires no intervention unless misuse occurs. The nurse would ensure proper dosing, as antidepressants support symptom control, improving quality of life without disrupting narcolepsy management strategies.

Chewing gum regularly is benign and unrelated to narcolepsy management. It may help with alertness but doesn’t warrant intervention. Unlike environmental factors like room temperature, gum has no significant impact on sleep quality or narcolepsy symptoms, making it an irrelevant focus for nursing education or correction.

A belief tool is not a standardized method for spiritual assessment. The FICA tool specifically evaluates faith, importance, community, and action, including questions about God and purpose. Assuming a vague belief tool risks incomplete assessment, missing critical spiritual needs that influence patient coping and well-being in holistic care settings.

The spiritual well-being scale measures general spiritual health but is not structured for detailed questions about God or life purpose, unlike the FICA tool’s targeted approach. Using this risks missing specific spiritual concerns, limiting the nurse’s ability to address existential needs critical for patient support in illness or end-of-life care.

The hope scale measures optimism but not specifically the relationship with God or life purpose, unlike the FICA tool’s broader spiritual focus. Assuming this method risks overlooking religious or existential concerns, reducing the effectiveness of spiritual care in addressing patient needs for meaning and satisfaction during health crises.

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.

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.

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.