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Zorluk: OrtaSelf-Care

An older adult client is recovering from a right total hip arthroplasty and is scheduled to begin independent morning hygiene and self-feeding. The practical nurse observes that the client, who was previously alert, is now suddenly disoriented and unable to follow simple grooming commands. Which actions should the practical nurse implement? Select all that apply.

  1. Guide the client through morning hygiene by providing one simple, short instruction at a time.Cevap
  2. B
    Reassure the family that the sudden onset of confusion is a normal, expected part of the aging process.
  3. Assist the client with a partial bed bath while ensuring the operative leg remains abducted.Cevap
  4. D
    Elevate the head of the bed to 90 degrees and sharply flex the client's knees to make self-feeding easier.
  5. Promptly notify the registered nurse regarding the client's acute change in cognition.Cevap
  6. F
    Prioritize completing the entire grooming routine before assessing vital signs or reporting the confusion.

Cevap

The correct actions are to provide one simple instruction at a time, assist with hygiene while keeping the operative leg abducted, and promptly notify the registered nurse of the cognitive change.
The practical nurse must promote client independence by breaking tasks into single, simple steps to accommodate the acute confusion. Additionally, assisting with a partial bed bath while keeping the leg abducted safely maintains postoperative hip precautions. Because sudden confusion is an acute change that may indicate a serious underlying physiological problem, the practical nurse must promptly report the finding to the registered nurse.

Adım Adım Çözüm

1
Recognize the significance of the acute cognitive change.
Identify that sudden disorientation is abnormal and represents a potential medical emergency (delirium), not a normal age-related change.
Sudden confusion can indicate hypoxia, infection, or medication adverse effects that take priority over routine care.
2
Adapt the self-care routine to the client's current cognitive ability.
Break down grooming tasks into single, short instructions.
This promotes the highest possible level of independence and reduces client frustration during periods of disorientation.
3
Maintain strict postoperative safety precautions during hygiene assistance.
Ensure the operative leg remains abducted and prevent the hip from flexing at or past 90 degrees.
Adhering to total hip arthroplasty precautions prevents joint dislocation while the client is moving in bed.
4
Escalate the clinical findings appropriately.
Notify the registered nurse and healthcare provider immediately.
The practical nurse must report acute deteriorations so that a comprehensive assessment and medical diagnosis can be made.

Anahtar Kavram

Promoting self-care and independence while maintaining postoperative safety and appropriately escalating acute changes in patient condition.
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