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. The lateral position refers to lying on one side with the top hip and knee flexed and the bottom hip and knee slightly flexed.
B. Dorsiflexion is the movement of the ankle joint in which the toes are brought closer to the shin or upward, as in the supine position described.
C. Contracture refers to the shortening or tightening of muscles, resulting in the inability to move the affected joint fully.
D. Plantar flexion is the movement of the ankle joint in which the toes are pointed downward or away from the shin, opposite to the position described.

A. Every 30 minutes B. Every 180 minutes C. Every 60 minutes D. Every 120 minutes

Correct Answer is D

Explanation

A. Changing the patient's position every 30 minutes can help prevent pressure sores but this is such a short interval. The recommended interval is at least every 2 hours.
B. Every 180 minutes (or every 3 hours) is too long of an interval between position changes for a patient at risk for skin impairment. Prolonged pressure on bony
prominences increases the risk of pressure ulcer development.

C. Every 60 minutes (or every hour) is more frequent than every 180 minutes but may

still not be sufficient for preventing pressure ulcers in an unconscious patient with limited mobility.
D. For an unconscious patient at risk for skin impairment, it is recommended to reposition the patient at least every two hours to prevent pressure ulcers and skin breakdown. This frequency is a balance between providing adequate skin protection and minimizing the risk of injury to the patient or strain to the healthcare provider.

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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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Naxlex Comprehensive Predictor Exams

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