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Making a pouch in the lower eyelid creates a cul-de-sac which is the site for initial instillation of the drops or ointment, to ensure the medication lands on the conjunctival sac. However, this action alone does not actively distribute the medication over the entire corneal and conjunctival surface; it is only the placement step. To promote even distribution, the instilled medication must be spread across the eye.

Gently rubbing the eyelids is generally contraindicated after instilling eye medication, as this action can cause local tissue irritation, increase medication absorption into the systemic circulation through the lacrimal duct, and potentially displace the medication too quickly, thereby reducing the intended therapeutic contact time on the eye surface.

Instilling medication drops onto the client's upper eyelid is ineffective and uncomfortable as the upper eyelid is a moving structure and the drops would likely run off immediately, or land on the lashes, preventing the medication from reaching the intended site, which is the conjunctival sac of the lower eyelid, a less sensitive and more receptive area for retention.

Making a pouch in the lower eyelid creates the space, known as the conjunctival sac, where the eye medication is initially instilled to ensure the drops or ointment land correctly. While essential for placement, this step does not actively facilitate the spreading of the medication across the corneal and conjunctival surfaces for full coverage and uniform absorption.

Gently rubbing the client's eyelids is generally discouraged because it can lead to unnecessary irritation of the eye and surrounding tissues. Furthermore, rubbing can inadvertently increase systemic absorption of the drug via the nasal mucosa after drainage through the nasolacrimal duct, potentially causing systemic side effects.

Instilling medication drops in the client's upper eyelid is inappropriate technique as the medication would not be reliably contained within the eye structures. The upper eyelid is not an optimal placement site; the medication is much more likely to be lost due to runoff, failing to reach the conjunctival sac or the cornea effectively for treatment.

Bathing actually enhances local circulation to the skin. The warm water and friction from washing and massaging stimulate vasodilation of peripheral blood vessels, increasing blood flow to the skin and subcutaneous tissues. This is beneficial for tissue oxygenation, nutrient delivery, and waste removal, not diminishing circulation.

While skin is involved in thermoregulation, primarily through sweating and vasodilation/constriction, the primary mechanism for maintaining core body temperature is internal physiological control. Bathing's effect is temporary, as warm water raises skin temperature briefly, which then returns to normal or slightly lower as water evaporates.

The skin and mucous membranes are separate systems. Bathing focuses on skin hygiene. The mucous membranes (e.g., mouth, nasal passages) are kept soft and moist primarily by continuous internal secretions (e.g., saliva, mucus). Bathing has a minimal direct effect on the moisture level of these internal, non-keratinized epithelial surfaces.

Tertiary care is highly specialized, complex medical care usually provided in referral centers for advanced disease or long-term management of complex conditions, such as neurosurgery or organ transplantation. Discharging a non-ambulatory stroke patient to a long-term care facility for activities of daily living assistance and monitoring is not considered tertiary level.

Secondary care involves services provided by specialists, often following a referral from primary care, such as acute hospital care for conditions like a CVA, or specialized consultations. The client has already received this acute care and is now moving to a setting focused on rehabilitation and custodial maintenance, not acute stabilization or diagnosis.

Primary care is the first point of contact for non-emergency healthcare, focusing on health promotion, disease prevention, and management of common illnesses (e.g., routine check-ups, flu shots, basic illness treatment). A long-term care facility stay for a non-ambulatory CVA client goes beyond the scope of general primary care services.

Anxiety is a relevant concern due to the dyspnea and overall severe symptoms, which can trigger a significant stress response. However, while important, anxiety is a psychological and emotional response to the physiological distress, not the underlying life-threatening physiological impairment. The physiological compromise must be addressed first.

The client exhibits signs of decreased cardiac output (BP 90/54, tachycardia) consistent with shock, likely septic given the infection signs (fever, cough). While critical, the primary cause of this systemic deterioration is the underlying infection and resulting poor oxygenation, which needs to be prioritized as it directly affects cell survival.

A Risk for Fall is present due to general malaise, potential for weakness from infection, and decreased cardiac output causing orthostatic changes. This is a safety consideration. However, it is not the most immediate threat to life compared to the severe respiratory distress and circulatory compromise evidenced by low PO_2 and hypotension.

Privacy is a general concern for all patients and children but is not the most critical, immediate concern specifically related to the pathophysiology of sleepwalking. While privacy might be a factor if the child's sleepwalking occurs in public or if they are self-conscious, the risk of physical harm inherent in an altered state of consciousness necessitates prioritizing safety over privacy in the initial teaching.

Nutrition can affect sleep quality, as deficiencies or imbalances may disrupt sleep architecture; however, there is no direct, established link suggesting that poor nutrition is a primary or sole cause of somnambulism. Addressing the immediate physical risk associated with the episode of unaware mobility is the most relevant and important topic for the nurse to discuss first.

Sleep deprivation can act as a trigger for somnambulism in susceptible individuals by increasing the pressure for slow-wave sleep, from which the event arises. While important to address, the immediate physical danger during an episode is a more pressing educational point than the potential precipitating factor. Ensuring the child's safety is the paramount concern. —.

The anger stage in the Kübler-Ross model is characterized by the patient reacting to the realization of their loss with hostility, frustration, and bitterness, often directed at healthcare providers, family, or even God. This is a move beyond initial disbelief and into the emotional impact of the diagnosis, which scientifically represents a shift in their coping mechanism.

Bargaining is a stage where the patient attempts to negotiate, often with a higher power, for a delay or reduction of the impending loss, frequently by making promises or changing lifestyle habits. This is a hope-driven effort to postpone the inevitable, representing a cognitive and emotional attempt to regain some control over the outcome.

Depression involves a phase of profound sadness, withdrawal, and hopelessness as the patient begins to fully grasp the certainty and magnitude of the loss. This emotional reaction is a form of preparatory grief, acknowledging the reality of the situation without the previous defenses of denial or bargaining.

Background provides context, including the patient's medical history, primary diagnosis, and relevant clinical details that led to the current situation. This information scientifically supports the current problem but is not where the action needed to correct the problem is explicitly stated.

Situation is the opening statement, providing a brief, clear identification of the patient and the immediate problem that necessitates communication. It establishes the urgency and nature of the call but does not include the suggested solution or action.

Assessment is the nurse's clinical judgment or interpretation of the current problem, including what they believe is happening with the patient and recent changes in vital signs or status. This scientifically justifies the need for action but is not the statement of the action itself. —.

Securing the tube with tape is an essential step to prevent accidental dislodgement or migration once correct placement is confirmed, but it does not confirm the initial placement of the distal tip in the stomach or small intestine. Relying on this action for confirmation risks administering substances into the lungs.

Checking the pH of aspirated fluid is a reliable method; aspirate with a pH of 0-4 strongly suggests gastric placement due to hydrochloric acid. However, chest X-ray is the gold standard for absolute confirmation, especially for small-bore tubes or when aspiration is difficult.

Auscultating for a whoosh sound over the epigastrium after injecting air is a less reliable and potentially misleading practice. Air instilled into a tube positioned in the esophagus or lungs can also produce a sound, leading to a false confirmation and high risk of pulmonary complication. —.