A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

Place their arms around the client to prevent the fall.

Remain upright as the client fails toward them.

Move quickly to a position in front of the client.

Allow the client to slide down their outstretched leg.

Answer and Explanation

The Correct Answer is D

A. This action may increase the risk of injury to both the nurse and the client.

B. This action does not effectively prevent the fall or minimize injury.

C. Moving quickly to a position in front of the client can cause imbalance and increase the risk for falling.
D. Allowing the client to slide down their outstretched leg can help prevent injury to both the client and the nurse.

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Correct Answer is B

Explanation

A. Extracellular fluid volume deficit (dehydration) typically leads to decreased venous return and reduced preload, resulting in flat or collapsed neck veins, rather than distended ones.
B. In extracellular fluid volume deficit, there is a decrease in blood volume, which can result in postural hypotension when the client changes positions, due to inadequate fluid volume to maintain blood pressure.
C. Extracellular fluid volume deficit is characterized by decreased fluid volume, which leads to decreased tissue perfusion and fluid shifts out of the interstitial spaces, resulting in reduced or absent edema.
D. Bradycardia is not typically associated with extracellular fluid volume deficit.

Instead, tachycardia may occur as a compensatory mechanism to maintain cardiac output in response to decreased blood volume.

A. Instruct the client to take deep, rhythmic breaths. B. Encourage the client to apply a heating pad for 2 hr at a time. C. Remove distractions from the client's room. D. Apply an ice pack to the client's back for 1 hr.

Correct Answer is A

Explanation

A. Deep breathing is a relaxation technique that can help reduce pain by increasing oxygen delivery, decreasing muscle tension, and promoting a sense of calmness. The nurse should instruct the client to breathe slowly and deeply through the nose and exhale through the mouth.
B. Heat therapy may provide relief for muscle-related back pain but should not be applied for prolonged periods as it may cause tissue damage.
C. Minimizing environmental stimuli can help the client focus on relaxation techniques and alleviate pain perception but is not as effective as deep breathing.
D. Ice therapy is typically used for acute pain or inflammation and may not be appropriate for mild, ongoing back pain.

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A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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