A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

Offer to adjust the height of the walker.

Explain the need to remove the wheels from the walker.

Demonstrate more coordinated movement of the legs and walker.

Encourage the client to continue using the walker as observed.

Answer and Explanation

The Correct Answer is A

A.   The walker should be adjusted to the client's height so that their elbows are slightly flexed when grasping the hand bars. This allows for proper weight-bearing and reduces strain on the shoulders and arms. Using a walker that is the correct height can help to prevent falls by providing better stability and support.
B.   Removing the wheels from the walker would make it difficult for the client to use. The wheels are an important feature of a walker, as they allow the client to move more easily.
C.   While demonstrating more coordinated movement may be helpful, it's not the most immediate action needed. Adjusting the height of the walker is a more important step to ensure the client's safety and comfort.
D.   Encouraging the client to continue using the walker as observed may not be appropriate if the walker is not adjusted to the correct height. A properly adjusted walker is essential for safe and effective mobility.

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Correct Answer is A

Explanation

A. This is a condition where the skin becomes hyperemic and hot after the application of heat. It's a sign of tissue damage and can lead to burns. Assessing for rebound phenomenon before applying a heating pad is crucial to prevent further injury.
B. While assessing range of motion can be helpful in determining the effectiveness of heat therapy, it's not the most important factor to consider before application.
C. Muscle strength and tone are not directly related to the risk of skin damage from heat therapy.
D. While neurosensory impairment can affect a client's ability to perceive heat and respond to pain, assessing for rebound phenomenon is a more direct way to evaluate the risk of skin damage.

A. Increase fiber in diet and add daily prune juice. B. Assess type and frequency of physical activities. C. Perform a digital examination for fecal impaction. D. Check bowel sounds and abdominal tenderness.

Correct Answer is D

Explanation

A. Increasing dietary fiber and adding prune juice can help relieve constipation by improving bowel regularity. While this is an important step in managing constipation, it is not the first action to take without understanding the underlying cause or current status of bowel function.
B. Physical activity is important for bowel regularity, especially post-surgery. However, assessing physical activity should come after a more immediate evaluation of the client's bowel status. It is crucial to first determine if there are other underlying issues that need addressing before implementing dietary changes or increasing activity.
C. A digital examination can be necessary to identify fecal impaction, especially if other assessments suggest severe constipation or if the client has not had a bowel movement for several days. However, this is an invasive procedure and should be performed based on preliminary findings from non-invasive assessments.
D. Checking bowel sounds and abdominal tenderness is an essential first step in assessing the client's gastrointestinal status. It helps identify whether there is a lack of bowel movement due to a more severe issue such as bowel obstruction or if it is simply a case of constipation.

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A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is A

Explanation

The nurse is completing an assessment of an older adult client recovering from a total hip replacement. The client reports a decreased appetite and is concerned about having not had a bowel movement for several days. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

On the first postoperative day, the nurse finds an older adult client disoriented and trying to climb over the bed railing. The client was oriented to person, place, and time on admission. Which intervention should the nurse implement first?

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The nurse observes a colleague putting printed copies of client information in a uniform pocket before going home. Which action should the nurse take?

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Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.

A client is having trouble breathing while lying in a dorsal recumbent position. Which action should the nurse implement first?