The nurse is providing morning care to a client with right arm hemiparesis. Which nursing action demonstrates use of the Self Care Model when planning care?
The nurse encourage autonomy by allowing the client time to wash their face and upper chest with the left arm
The nurse performs range of motion exercises to the right arm
The nurse recognizes due to cultural preferences a female should provide the bed bath
The nurse performs all the tasks
The Correct Answer is A
A. The nurse encourages autonomy by allowing the client time to wash their face and upper chest with the left arm: The Self Care Model focuses on promoting independence and encouraging clients to do as much for themselves as possible. Allowing the client to perform tasks within their ability fosters autonomy and self-care.
B. The nurse performs range of motion exercises to the right arm: While beneficial, this does not directly promote the client's independence in self-care.
C. The nurse recognizes due to cultural preferences a female should provide the bed bath: This respects cultural preferences but does not relate directly to promoting self-care.
D. The nurse performs all the tasks: This does not encourage the client’s independence and is not aligned with the Self Care Model.
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Related Questions
Correct Answer is A
Explanation
A. The nurse determines the client’s readiness to learn: Assessing the client's readiness to learn is part of the assessment phase of the teaching plan. It involves evaluating the client’s emotional and cognitive state to ensure they are prepared to absorb new information.
B. The nurse discusses types of food that the client needs to avoid: This is part of the teaching or implementation phase, not the assessment phase.
C. The nurse describes which supplies would be needed: Describing necessary supplies is also part of the teaching or implementation phase.
D. Ask the client to demonstrate emptying of the colostomy bag: This is part of the evaluation phase, where the nurse assesses the client’s ability to perform the task taught.
Correct Answer is B
Explanation
A. Speak loudly and use simple words: Speaking loudly may be perceived as shouting and can increase agitation. Using simple words is appropriate, but volume should be normal and calm.
B. Address the client by name and reorient client: Addressing the client by name and reorienting him is effective because it respects his dignity and helps him understand his current situation, reducing confusion and agitation. This approach is clear, respectful, and supportive.
C. Challenge the client to refocus his attention when he becomes agitated: Challenging the client can be confrontational and may escalate agitation. It is better to use a calm, reassuring approach.
D. Ask the client a series of questions without allowing time for the client to answer: This can overwhelm and frustrate the client, leading to increased agitation.
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