A nurse is assisting in performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels?

Maximum assist

Minimal assist

Moderate assist

No assist

Answer and Explanation

The Correct Answer is B

A.   Maximum assist is when the client requires total assistance from one or more persons to perform the activity. In this scenario, the client is able to rise from a seated position
independently with the assistance of a cane, so maximum assist is not appropriate.
B.   Minimal assist is when the client requires some assistance or supervision to perform the activity but is able to complete most of the task independently. Since the client can rise from a seated position using a cane for support, they require minimal assistance.
C.   Moderate assist is when the client requires more help than minimal assist but can still contribute to the activity. Since the client can perform the task with minimal assistance, moderate assist is not appropriate.
D.   No assist is when the client is able to perform the activity without any assistance.
While the client uses a cane for support, they are still able to rise from a seated position independently, so no assist is not appropriate.

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Correct Answer is B

Explanation

A. Standing close to the patient is a recommended practice to maintain proximity and control during patient transfers. This action is appropriate and does not require
intervention.
B. Twisting at the torso can lead to strain or injury to the nurse's back. It is essential to avoid twisting while performing patient transfers to maintain proper body mechanics and prevent injury.
C. Maintaining a wide base of support is important for stability and balance during patient transfers. This action is appropriate and promotes safe transfer techniques.
D. Using proper body mechanics is crucial for preventing injury during patient transfers.

However, the specific concern in this scenario is twisting at the torso, which can lead to strain or injury, rather than overall body mechanics.

A. List of medications B. Treatment C. Medical condition D. Vital signs

Correct Answer is C

Explanation

A. The list of medications is typically included in the Background component of the ISBARR communication tool, as it provides important information about the client's ongoing treatment and medications.

B. Treatment plans and interventions are generally discussed in the Assessment and Recommendation components of the ISBARR communication tool, as they involve the nurse's assessment of the client's condition and the actions recommended for continued care.
C. The Situation component of the ISBARR communication tool focuses on providing a concise summary of the client's current medical condition or status, including relevant changes since the last report or significant events that occurred during the shift.
D. Vital signs may be included as part of the Background or Assessment components of the ISBARR communication tool, depending on their relevance to the client's current condition and any changes observed during the shift.

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A nurse is assisting in performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels?

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