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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "There are no provider's prescriptions available." This statement is about the current situation or background, not a recommendation.
B. "The client should be seen by a neurologist." The Recommendation (R) step involves suggesting actions or solutions, such as recommending that the client be seen by a neurologist.

C. "The client is disoriented. Pupils are slow to respond to light." This statement belongs in the Assessment (A) step as it describes the nurse’s clinical findings.
D. "The client was found unconscious on the floor in her home." This statement provides background information (B) about the client’s situation.

A. Assessment B. Evaluation C. Planning D. Implementation

Correct Answer is B

Explanation

A. Assessment: Assessment is the initial data collection phase before intervention.
B. Evaluation: Evaluation involves determining the effectiveness of an intervention. Checking blood sugar after administering insulin is evaluating the effectiveness of the insulin.
C. Planning: Planning involves setting goals and deciding on interventions, not the follow-up.
D. Implementation: Implementation involves carrying out the planned interventions, such as administering insulin, not checking the results.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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