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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Clarification: Clarification is a technique used to ensure that the nurse understands the client’s feelings and concerns correctly. By asking if the client is feeling anxious about the results, the nurse is clarifying the client’s statement.
B. Providing information: Providing information involves giving facts or details to the client, not seeking to understand their feelings.
C. Confrontation: Confrontation involves addressing discrepancies in the client’s statements or behaviors, which is not applicable in this situation.
D. Summarizing: Summarizing involves reviewing main points of the conversation, not clarifying feelings.
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