The nurse is providing morning care to a client with right arm hemiparesis. Which nursing action demonstrates use of the Self Care Model when planning care?
The nurse encourage autonomy by allowing the client time to wash their face and upper chest with the left arm
The nurse performs range of motion exercises to the right arm
The nurse recognizes due to cultural preferences a female should provide the bed bath
The nurse performs all the tasks
The Correct Answer is A
A. The nurse encourages autonomy by allowing the client time to wash their face and upper chest with the left arm: The Self Care Model focuses on promoting independence and encouraging clients to do as much for themselves as possible. Allowing the client to perform tasks within their ability fosters autonomy and self-care.
B. The nurse performs range of motion exercises to the right arm: While beneficial, this does not directly promote the client's independence in self-care.
C. The nurse recognizes due to cultural preferences a female should provide the bed bath: This respects cultural preferences but does not relate directly to promoting self-care.
D. The nurse performs all the tasks: This does not encourage the client’s independence and is not aligned with the Self Care Model.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessment: The Assessment section includes the nurse's findings and interpretations of the client's current condition. Information specific to sleep apnea would more likely be part of the client's history and not a direct assessment finding at this time.
B. Background: The Background section includes relevant background information that could impact the client’s current situation. This would be the appropriate section to include the client's history of sleep apnea.
C. Situation: The Situation section focuses on the current issue or reason for the communication. While it should be concise, it does not include detailed past medical history unless directly relevant to the current situation.
D. Recommendation: The Recommendation section is where the nurse suggests the next steps or interventions needed. Information about sleep apnea is not a recommendation but part of the client's background.
Correct Answer is C
Explanation
A. "The vital signs are stable." This statement belongs in the Assessment (A) step, as it provides information about the client’s current clinical condition.
B. "The client has a history of high blood pressure." This statement belongs in the Background (B) step, providing relevant medical history.
C. "The client is disoriented. Pupils are slow to respond to light." The S (Situation) step involves stating the immediate problem or reason for the communication. Describing the client's disorientation and pupil response directly addresses the current issue that prompted the call.
D. "The client should be seen by a neurologist." This statement belongs in the Recommendation (R) step, suggesting the next course of action.
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