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Difficulty: HardSelf-Care

An interdisciplinary team is preparing to discharge a client who recently experienced a left-hemisphere cerebrovascular accident (CVA) with resulting right-sided hemiparesis. The primary nurse is finalizing the client's independent living and self-care directives. Which of the following interventions should the nurse incorporate into the plan of care? Select all that apply.

  1. Instruct the client to put their right arm into shirtsleeves first before dressing the left arm.Answer
  2. Advise the installation of grab bars and the use of a seated shower bench to maximize bathing independence.Answer
  3. C
    Delegate the initial assessment of the client's home medication self-administration skills to the unlicensed assistive personnel (UAP).
  4. D
    Explain to the family that the client's sudden onset of urinary incontinence over the past 24 hours is an expected change of the aging process.
  5. E
    Assume the family prefers to perform all basic hygiene tasks for the client based on their stated ethnicity, omitting self-care training.
  6. Encourage the client to use a rocker knife and plate guard to facilitate independent feeding.Answer

Answer

The correct interventions are instructing the client to dress the right arm first, advising the use of a shower bench and grab bars, and encouraging the use of adaptive feeding tools like a rocker knife.
Promoting self-care after a stroke involves utilizing adaptive strategies that accommodate the client's physical deficits. Because a left-brain stroke causes right-sided weakness, the client should dress the right (affected) side first to avoid excessive manipulation of the impaired limb. Recommending structural adaptations, such as grab bars and a shower bench, and introducing adaptive dining equipment, such as a rocker knife, directly support the client's ability to safely perform activities of daily living (ADLs) independently.

Step-by-Step Solution

1
Analyze the client's pathophysiology.
A left-hemisphere CVA results in right-sided hemiparesis (weakness).
Understanding the specific functional deficits is required to determine the appropriate self-care modifications.
2
Evaluate each dressing and hygiene intervention.
Dressing the affected (right) side first and using shower safety equipment are identified as safe and therapeutic strategies.
These methods accommodate the weakness, prevent joint strain, and reduce fall risk while promoting autonomy.
3
Identify inappropriate or unsafe nursing actions among the choices.
Delegating initial assessment to a UAP, stereotyping cultural preferences, and ignoring acute incontinence as 'normal aging' are identified as incorrect actions.
These actions violate principles of safe delegation, cultural competence, and pathophysiological assessment.

Key Concept

The nurse promotes self-care independence in hemiparetic clients through targeted adaptive equipment, specific sequencing for ADLs (dressing the affected side first), and individualized assessment, while avoiding improper delegation and cultural assumptions.
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Self-Care

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