A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?
Postpone ADLS until an occupational therapist determines the client's abilities.
Eliminate daily care that is not essential for the client's recovery.
Inform the client of the time the ADLS will be performed.
Determine the client's preferences.
The Correct Answer is C
A. Postpone ADLs until an occupational therapist determines the client's abilities. Delaying ADLs can lead to decreased independence and a decline in the client's physical condition. The nurse should assess the client's abilities and provide appropriate assistance.
B. Eliminate daily care that is not essential for the client's recovery. All aspects of daily care contribute to the client's overall well-being and quality of life. Eliminating non-essential care can negatively impact the client's mental and physical health.
C. Inform the client of the time the ADLs will be performed. Informing the client of the time the ADLs will be performed promotes consistency and allows the client to prepare mentally and physically. This helps maintain a routine, which can be reassuring for the client.
D. Determine the client's preferences. While it is important to consider the client's preferences, it is not the primary action. Informing the client of the schedule helps with planning and consistency.
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Related Questions
Correct Answer is D
Explanation
A. Plan to initiate a bladder retraining program for the client. This is important but not the immediate first action.
B. Protect the client's perineal skin with a moisture barrier. This is a preventive measure but not the first step in evidence-based practice.
C. Teach the client to perform pelvic floor muscle exercises. This is useful but not the immediate first action.
D. Request a prescription for catheter removal. Indwelling urinary catheters should be removed as soon as possible to reduce the risk of infection, which aligns with evidence-based practice.
Correct Answer is C
Explanation
A. Postpone ADLs until an occupational therapist determines the client's abilities. Delaying ADLs can lead to decreased independence and a decline in the client's physical condition. The nurse should assess the client's abilities and provide appropriate assistance.
B. Eliminate daily care that is not essential for the client's recovery. All aspects of daily care contribute to the client's overall well-being and quality of life. Eliminating non-essential care can negatively impact the client's mental and physical health.
C. Inform the client of the time the ADLs will be performed. Informing the client of the time the ADLs will be performed promotes consistency and allows the client to prepare mentally and physically. This helps maintain a routine, which can be reassuring for the client.
D. Determine the client's preferences. While it is important to consider the client's preferences, it is not the primary action. Informing the client of the schedule helps with planning and consistency.
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