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Difficulty: Very hardSelf-Care

A home health nurse is developing a comprehensive self-care and health promotion plan for an older adult client who has advanced rheumatoid arthritis (RA), severe left-sided heart failure, and type 2 diabetes mellitus with advanced peripheral neuropathy. Which of the following interventions should the nurse include in the client's plan of care? Select all that apply.

  1. Instruct the client to perform daily foot inspections using a shatterproof, long-handled mirror placed on the floor.Answer
  2. Teach the client to conserve energy and protect joints by sliding heavy objects, such as pots, across countertops rather than lifting them.Answer
  3. C
    Reassure the client that increasing forgetfulness regarding their complex medication regimen is a normal physiological part of the aging process.
  4. D
    Delegate the initial assessment of the client's home environment and capacity to perform activities of daily living to the unlicensed assistive personnel (UAP).
  5. Instruct the client to notify the healthcare provider immediately for a weight gain of 3 lb (1.4 kg) over 2 days or the onset of paroxysmal nocturnal dyspnea.Answer
  6. F
    Document that the client's upcoming diabetic retinopathy examination and bone mineral density scan demonstrate adherence to primary disease prevention.

Answer

The nurse should instruct the client to use a long-handled mirror for foot inspections, slide heavy objects across counters to protect joints, and immediately report rapid weight gain or paroxysmal nocturnal dyspnea.
The appropriate interventions address the client's complex comorbidities while promoting safety and independence. Using a long-handled mirror accommodates limited mobility from rheumatoid arthritis (RA) while ensuring essential diabetic foot care. Sliding objects protects fragile joints affected by RA. Monitoring for a rapid weight gain or paroxysmal nocturnal dyspnea is a critical self-care parameter for early detection of heart failure exacerbations.

Step-by-Step Solution

1
Analyze the client's comorbidities and their specific self-care and health promotion requirements.
The client has rheumatoid arthritis (requires joint protection and mobility adaptations), severe heart failure (requires fluid and weight monitoring), and diabetic neuropathy (requires rigorous foot care and injury prevention).
Identifying the distinct physiological needs and limitations of each pathology is essential for creating a safe, highly individualized care plan.
2
Evaluate each proposed intervention against evidence-based practices, patient safety guidelines, and the nursing scope of practice.
Using a long-handled mirror, sliding heavy objects, and reporting acute weight gain correctly address the client's clinical needs. Delegating initial assessments, dismissing memory loss as normal aging, and misclassifying secondary prevention as primary prevention are incorrect actions.
Nursing interventions must be clinically sound, within the RN scope of practice, and based on accurate physiological and theoretical principles.

Key Concept

Integration of Self-Care Practices for Complex Comorbidities
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Topics

Self-Care

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