A nurse is instructing a nursing assistant on how to assist a patient with bathing.
The patient has hemiparesis on the left side due to a stroke.
Which of the following statements by the nursing assistant demonstrates understanding of the teaching?
"I will wash the patient's left side first, then move to the right side.”.
"I will wash the patient's right side first, then move to the left side.”.
"I will wash both sides of the patient at the same time, starting from the head and moving down.”.
"I will ask the patient which side they prefer to wash first, then follow their preference.".
The Correct Answer is D
Choice A rationale:
Washing the patient's left side first and then moving to the right side does not demonstrate an individualized approach or consideration for the patient's preferences and abilities. It is important to involve the patient in the decision-making process, especially when they have hemiparesis, to promote their autonomy and comfort.
Choice B rationale:
Washing the patient's right side first and then moving to the left side does not consider the patient's preference and may not align with their abilities or comfort. It is essential to prioritize the patient's preferences and needs.
Choice C rationale:
Washing both sides of the patient at the same time, starting from the head and moving down, may not be feasible or comfortable for the patient, especially if they have hemiparesis. This approach does not demonstrate an individualized care plan based on the patient's specific condition.
Choice D rationale:
Asking the patient which side they prefer to wash first and then following their preference is the most patient-centered and appropriate approach. This approach respects the patient's autonomy and ensures that their needs and comfort are prioritized during the bathing process. It allows for individualized care based on the patient's abilities and preferences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.
Choice B rationale:
Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.
Choice C rationale:
Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.
Choice D rationale:
Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.
Correct Answer is B
Explanation
The correct answer is choice b. “Curling’s ulcer.”
Choice A rationale:
Elevated blood pressure is not a common complication specifically associated with partial-thickness burns. It may occur due to pain or stress but is not the most critical complication to anticipate.
Choice B rationale:
Curling’s ulcer, a type of stress ulcer, is a significant complication that can develop in burn patients due to the stress response and reduced blood flow to the gastrointestinal tract.
Choice C rationale:
Compartment syndrome is more commonly associated with circumferential full-thickness burns rather than partial-thickness burns.
Choice D rationale:
Excruciating pain is a symptom rather than a complication. While pain management is crucial, it is not the most critical complication to anticipate.
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