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Difficulty: HardSelf-Care

A practical nurse is providing morning care for an older adult client of Orthodox Jewish faith who is participating in a subacute rehabilitation program following a right-hemisphere stroke. The client exhibits left-sided weakness and unilateral neglect. During the morning routine, the practical nurse implements strategies to promote the client's independence with activities of daily living (ADLs). Which of the following actions by the practical nurse are appropriate? Select all that apply.

  1. Provide assistive devices such as a rocker knife and a plate guard for the morning meal.Answer
  2. Position the client's washbasin and grooming supplies within easy reach on their right side.Answer
  3. C
    Attribute a sudden, acute onset of disorientation during grooming to expected age-related cognitive decline.
  4. D
    Serve the standard facility breakfast tray containing non-kosher items to ensure the client receives immediate nutrition.
  5. E
    Accept a delegated task from the registered nurse to conduct the initial clinical evaluation of the client's swallowing reflex.
  6. Allocate additional time in the morning schedule to allow the client to complete upper body dressing at their own pace.Answer

Answer

The appropriate actions are providing assistive eating devices, positioning grooming supplies on the unaffected right side, and allocating extra time for dressing.
The correct actions promote client independence while maintaining safety and respecting individualized needs. Providing adaptive eating utensils, placing grooming items on the unaffected right side (accommodating left-sided weakness and neglect), and allowing sufficient time for tasks all empower the client to perform ADLs safely without the nurse unnecessarily taking over the activities.

Step-by-Step Solution

1
Analyze the client's clinical profile and functional deficits.
The client has left-sided weakness and neglect, requires stroke-specific ADL support, and follows a strict religious diet.
Understanding the client's specific physical limitations and cultural needs is essential for planning individualized self-care.
2
Evaluate each potential intervention against the practical nurse's scope of practice and safety standards.
Conducting initial swallowing evaluations is outside the PN scope. Furthermore, acute confusion indicates a potential medical emergency (delirium or neurological change), not normal aging.
Ensuring actions are safe and legally within the PN scope of practice protects the client from harm.
3
Identify strategies that specifically promote self-care and independence.
Using adaptive equipment, placing items within the intact visual/motor field, and allowing sufficient time safely maximize the client's ability to complete ADLs independently.
The primary goal of rehabilitation nursing is to empower the client to regain maximum functional independence.

Key Concept

Promoting Independence in Activities of Daily Living (ADLs)
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Topics

Self-Care

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