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Zorluk: OrtaSelf-Care

A client on a medical-surgical unit has left-sided weakness following a recent cerebrovascular accident. The interdisciplinary care plan focuses on restoring the client's ability to independently perform activities of daily living (ADLs). When assisting the client with morning routines and breakfast, which action by the practical nurse is most appropriate?

  1. A
    Attribute a sudden onset of disorientation and inability to grasp the toothbrush to normal cognitive decline, taking over the grooming tasks entirely.
  2. Place grooming utensils and approved meal items on the client's unaffected side while guiding them with brief, sequential verbal prompts.Cevap
  3. C
    Direct the nursing assistant to conduct the first clinical assessment of the client's swallowing coordination before providing the adaptive feeding equipment.
  4. D
    Request a generic pureed meal tray from dietary services to decrease energy expenditure during feeding, omitting verification of the client's specific religious food laws.

Cevap

The most appropriate action is to place grooming utensils and meal items on the client's unaffected side while providing brief, sequential verbal prompts.
The correct intervention actively supports the care plan's goal of maximizing independence. By placing items within reach of the client's functional side and offering step-by-step verbal cues, the practical nurse accommodates the physical deficit while keeping the client actively engaged in their own care.

Adım Adım Çözüm

1
Analyze the client's physical and cognitive deficits based on the scenario.
The client has left-sided weakness, meaning interventions must utilize the right (unaffected) side to enable physical movement.
Identifying the functional limitations dictates the physical setup required for self-care.
2
Evaluate the primary nursing goal outlined in the care plan.
The goal is to maximize independence in activities of daily living (ADLs).
Interventions must encourage the client to perform tasks themselves rather than having the nurse do the tasks for them.
3
Select the intervention that best aligns with the goal and client capabilities.
Using the unaffected side for physical access and providing sequential verbal cues supports both motor and cognitive processing.
This approach bridges the physical deficit and maintains client autonomy without violating safety protocols or scope of practice.

Anahtar Kavram

Promoting Independence in Self-Care (ADLs)
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Konular

Self-Care

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