A nurse is caring for a client with limited mobility due to recent surgery. What is the most appropriate intervention to ensure the client's personal hygiene needs are met?

Assess the client's ability and assist with tasks they cannot perform

Focus only on oral hygiene as it is the most important aspect of personal care.

Encourage the client to perform all hygiene tasks independently

Provide full assistance with hygiene tasks without involving the client.

Answer and Explanation

The Correct Answer is A

A. Assess the client's ability and assist with tasks they cannot perform: Individualized assessment allows the nurse to determine which hygiene activities the client can safely perform and where assistance is needed. This approach promotes independence, preserves dignity, and prevents complications such as skin breakdown. It aligns with patient-centered care and postoperative recovery principles.

B. Focus only on oral hygiene as it is the most important aspect of personal care: Oral hygiene is important, but neglecting other aspects such as skin care, perineal care, and bathing increases the risk of infection and impaired comfort. Comprehensive hygiene is necessary for overall health. Limiting care to one area is inadequate.

C. Encourage the client to perform all hygiene tasks independently: While independence is encouraged, recent surgery and limited mobility may make some tasks unsafe or impossible. Forcing independence can increase fatigue, pain, or risk of injury. Nursing care should balance support with autonomy.

D. Provide full assistance with hygiene tasks without involving the client: Performing all hygiene tasks without involving the client reduces independence and can negatively affect self-esteem. Participation promotes mobility, circulation, and a sense of control. Total care is not indicated unless the client is completely dependent.

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Correct Answer is A

Explanation

A. Administer oxygen therapy to improve oxygen saturation levels: According to Maslow’s hierarchy, physiologic needs such as oxygenation take highest priority. Hypoxemia compromises cellular metabolism and can rapidly become life-threatening if not corrected. Immediate oxygen therapy supports airway and breathing, making it the nurse’s first action.

B. Provide emotional support to the patient: Emotional reassurance addresses psychosocial needs, which are important but secondary to physiologic stability. A patient experiencing shortness of breath requires correction of oxygen imbalance before anxiety can be effectively managed. Psychological support is more effective once oxygenation improves.

C. Discuss the patient's concerns about their safety in the hospital: Safety concerns fall under Maslow’s safety and security needs. While relevant, these needs are prioritized after physiologic needs such as adequate oxygen delivery. Addressing safety without stabilizing breathing places the patient at continued risk.

D. Assist the patient in meeting their self-actualization needs: Self-actualization represents the highest level of Maslow’s hierarchy and is only addressed after all basic and psychological needs are met. A patient with respiratory compromise is not physiologically stable enough for this level of intervention.

A. Distributing pamphlets about local health services without collaboration B. Providing Individual health assessments for every community member. C. Directing all community members to the nearest urban health center D. Partnering with local schools to implement health education programs.

Correct Answer is D

Explanation

A. Distributing pamphlets about local health services without collaboration: Providing information alone is a passive approach and may not reach or engage the community effectively. Without collaboration, the intervention may lack cultural relevance and sustainability.

B. Providing individual health assessments for every community member: While comprehensive, this approach is resource-intensive and may be impractical in a rural setting with limited staff and access. It does not leverage community resources for broader impact.

C. Directing all community members to the nearest urban health center: Referring the population to urban centers may create barriers related to transportation, cost, and accessibility. It does not provide locally accessible care or education.

D. Partnering with local schools to implement health education programs: Collaboration with schools provides an accessible, sustainable platform to reach a broad segment of the community. School-based interventions promote health literacy, preventive behaviors, and community engagement, making it the most effective collaborative approach.

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A nurse is caring for a client with limited mobility due to recent surgery. What is the most appropriate intervention to ensure the client's personal hygiene needs are met?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is experiencing shortness of breath and has low oxygen saturation levels. According to Maslow's hierarchy of needs, what should be the nurse's first action?

Correct Answer is A

Explanation

A nurse is creating a community health intervention plan for a rural population with limited access to healthcare. Which collaborative intervention is most appropriate to address this issue?

Correct Answer is D

Explanation

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A nursing student accesses a patient's electronic health record for a class assignment without the patient's consent. What HIPAA provision does this action violate?