A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

Postpone ADLS until an occupational therapist determines the client's abilities.

Eliminate daily care that is not essential for the client's recovery.

Inform the client of the time the ADLS will be performed.

Determine the client's preferences.

Answer and Explanation

The Correct Answer is C

A. Postpone ADLs until an occupational therapist determines the client's abilities. Delaying ADLs can lead to decreased independence and a decline in the client's physical condition. The nurse should assess the client's abilities and provide appropriate assistance.
B. Eliminate daily care that is not essential for the client's recovery. All aspects of daily care contribute to the client's overall well-being and quality of life. Eliminating non-essential care can negatively impact the client's mental and physical health.
C. Inform the client of the time the ADLs will be performed. Informing the client of the time the ADLs will be performed promotes consistency and allows the client to prepare mentally and physically. This helps maintain a routine, which can be reassuring for the client.
D. Determine the client's preferences. While it is important to consider the client's preferences, it is not the primary action. Informing the client of the schedule helps with planning and consistency.

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Correct Answer is B

Explanation

A. Provide an analgesic for pain. Administering medication is important but should be done after assessing the pain.
B. Obtain a self-report from the client. The client's self-report is the most reliable indicator of pain and should be obtained first.
C. Observe the client's behaviors. Observing behaviors is helpful but should follow the self-report to validate the client's experience.
D. Develop a behavioral pain score. This can be useful for non-verbal clients, but the self-report is the primary method of assessment for verbal clients.

A. Ask the client to describe his spiritual beliefs. B. Provide available resources on spiritual care for the client. C. Consult a dietitian to incorporate the client's religious preferences into a meal plan. D. Offer to contact the local leader of the client's religious group.

Correct Answer is A

Explanation

A. Ask the client to describe his spiritual beliefs. This is correct. Understanding the client’s spiritual beliefs is the first step in providing appropriate and individualized care.
B. Provide available resources on spiritual care for the client. Providing resources is helpful but should follow an understanding of the client’s specific needs and beliefs.
C. Consult a dietitian to incorporate the client's religious preferences into a meal plan. This is important for comprehensive care but is not the first step in addressing spiritual distress related to treatment conflicts.
D. Offer to contact the local leader of the client's religious group. Contacting a religious leader can be supportive, but the first step should be to understand the client’s specific spiritual beliefs and concerns.

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