A nurse in a long-term care facility is assisting in planning care for a group of clients. For which of the following clients can the nurse safely gait belt?

A client who is displaying aggression

A client who has had chest trauma.

A client who has limited arm strength.

A client who has a thoracic incision.

Answer and Explanation

The Correct Answer is C

A. A client who is displaying aggression: Using a gait belt on an aggressive client is unsafe because sudden movements or resistance could lead to injury for both the client and the caregiver. Aggressive behavior requires de-escalation strategies before considering physical assistance or mobility interventions like a gait belt.

B. A client who has had chest trauma: Gait belts should be avoided in clients with chest trauma because the pressure applied around the torso can exacerbate injuries such as rib fractures, pulmonary contusions, or other thoracic complications, posing significant health risks during mobilization.

C. A client who has limited arm strength: A gait belt is appropriate for clients with limited arm strength because it provides secure support around the waist without requiring the client to rely heavily on their upper limbs. It allows for safer ambulation and transfer by offering the caregiver a firm point of control.

D. A client who has a thoracic incision: Applying a gait belt over or near a thoracic incision can interfere with wound healing, cause pain, and increase the risk of wound dehiscence. Alternative methods for assisting mobility should be used for clients with fresh surgical sites in the thoracic region.

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Correct Answer is D

Explanation

A. The client recently received a pay raise at work: Receiving a pay raise is generally considered a positive life event that can improve self-esteem and financial security. Positive achievements like this are not associated with increased suicide risk and may actually serve as protective factors against depressive symptoms.

B. The client is married and has children: Being married and having children are typically viewed as protective factors against suicide. Strong familial bonds and social connections provide emotional support, a sense of responsibility, and a buffer against feelings of isolation or hopelessness that often contribute to suicidal ideation.

C. The client has a strong religious affiliation: Strong religious beliefs can serve as a significant protective factor against suicide by providing hope, purpose, community support, and moral objections to self-harm. Clients with strong spiritual ties often demonstrate greater resilience during periods of emotional distress.

D. The client has a history of chronic back pain: Chronic pain is a known risk factor for suicide because it can lead to feelings of hopelessness, helplessness, and a diminished quality of life. Clients with long-term physical pain often experience comorbid depression and are at higher risk for suicidal thoughts and behaviors.

A. A B. B C. None D. None E. None F. None

Correct Answer is B

Explanation

A: Image A shows the ankle area, which is an example of a hinge joint, not a ball and socket joint. Hinge joints allow movement in one plane, such as flexion and extension, similar to the motion of a door hinge. The ankle allows primarily up-and-down movement but does not rotate in multiple directions like a ball and socket joint would.

B: Image B shows the hip area, which represents a ball and socket joint. In a ball and socket joint, the round head of one bone fits into the cup-like socket of another bone, allowing movement in multiple directions. The hip and the shoulder are classic examples of ball and socket joints, permitting rotation, flexion, extension, abduction, and adduction.

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A nurse in a long-term care facility is assisting in planning care for a group of clients. For which of the following clients can the nurse safely gait belt?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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