NURSING PROCESS The nurse’s assessment findings include right sided weakness, slurred speech, and dysphagia. The nurse identifies that Mrs. Rusk is at high risk for several problems. 1. In developing the nursing plan of care, which problem has the highest priority? A. Aspiration B. Skin Breakdown C. Altered nutrition D. Self care deficit

A. Aspiration – Rationale: Aspiration, or the entry of foreign substances such as food or fluids into the lungs, may cause hypoxia or respiratory distress. Therefore, this is the highest priority in establishing the client’s plan of care. More test answers on https://studyhippo.com/hesi-altered-nutrition-2/

The nurse notes that the client often sighs and says in a monotone voice, “I’m never going to get over this.” When encouraged to participate in care, the client says, “I don’t have the energy.” The nurse believes these cues are suggestive of which nursing diagnoses? Select all that apply. A. Hopelessness B. Powerlessness C. Interrupted sleep pattern D. Disturbed self esteem E. Self care deficit

A. Hopelessness B. Powerlessness Rationale: Rationale: A nursing diagnosis is a clinical judgment about a response to an actual or potential health problem. This client is manifesting symptoms of both hopelessness and powerlessness. Although the client does report symptoms compatible with fatigue, there is no direct data is given that indicates the client has interrupted sleep patterns (option 3), disturbed self esteem (option 4), or self care deficit (option 5). More test answers on https://studyhippo.com/nclex-questions-nursing-process/

Dorothea E. Orem: self care deficit nusing theory

-focus of person as an agent -3 nested theories: 1. self care 2. self deficit 3. nursing systems -other concepts: self care reqs, universal, developmental and health deviation self care reqs, deliberate action, product of nursing More test answers on https://studyhippo.com/theory-in-nursing-final-ch-7-grand-theories-based-on-human-needs/

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What is Self Care Deficit?

The Self Care Deficit Nursing Theory was developed by Dorothea Orem in the 1950s. This theory is based on the premise that individuals are responsible for their own self-care and health maintenance, but may require assistance from a nurse in order to do so effectively. The goal of this theory is to help nurses provide care that will enable an individual to meet his or her personal needs. At its core, this theory suggests that all individuals have a basic need for self-care and health maintenance which must be met in order for them to remain healthy. It also states that nurses should assess the patient’s ability to perform these activities independently, offering support when needed. This includes providing education about proper nutrition, exercise, hygiene habits and other lifestyle changes which can improve overall wellbeing. The principles of this theory include five distinct concepts: 1) Self Care Requisites; 2) Health Deviation Resources; 3) Therapeutic Self Care Demands; 4) Nursing Systems; 5) Nursing Processes. Self Care Requisites refer to those activities necessary for maintaining good health such as eating right, exercising regularly and getting adequate rest. Health Deviation Resources are those external resources available to patients who may not be able to provide themselves with adequate self care such as community programs or family members who can assist with taking medications or transportation needs. Therapeutic Self Care Demands define what type of nursing interventions might be necessary in specific situations such as wound dressing or administering medications if prescribed by doctors. Nursing Systems describe how nurses interact with patients through assessments, planning and implementation of interventions including advice and guidance aimed at promoting positive outcomes for the patient’s well being along with evaluating progress made towards goals set between nurse-patient relationship over time . Finally, Nursing Processes involve using evidence based practice methods in carrying out duties related directly with nursing intervention plans created specifically for each patient depending upon their individual needs . All together , it is essential that healthcare professionals understand the underlying principles behind this model so they can better provide optimal care tailored towards each patient’s individual situation while still adhering strictly to professional standards .