A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?
Ask the client to stand for 5 seconds.
Ask the client to place their feet on the floor.
Ask the client to sit on the edge of the bed for 2 min.
Ask the client to march in place.
The Correct Answer is C
A) Standing requires more mobility and strength; it's not the first step in assessing mobility.
B) Placing feet on the floor assesses the client's ability to follow instructions and indicates readiness for further mobility assessments but is not the first step compared to sitting on the edge of the bed for 2 minutes.
C) This is the first action that the nurse should take to assess the client's mobility and balance. Sitting on the edge of the bed for 2 min allows the nurse to observe the client's posture, strength, coordination, and ability to maintain equilibrium.
D) This is a more advanced mobility assessment and should come after basic assessments like placing feet on the floor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Tucking the chin may be appropriate to maintain spinal alignment, but this statement does not address overall posture during client transfers.
B) Maintaining a straight back helps distribute weight evenly and reduces the risk of injury to the spine during client transfers.
C) Keeping the knees straight may lead to increased strain on the back and legs during transfers, and it is not recommended.
D) Engaging the abdominal muscles helps stabilize the core and protect the spine during transfers; therefore, they should not be loosened.
Correct Answer is C
Explanation
A. Minimal assist means that the client needs some verbal cues or light touch to perform an activity.
B. Moderate assist means that the client needs physical assistance from one person to perform an activity.
C. The client's ability to rise from a seated position using a cane for support indicates that they require no assistance from the nurse or another person to perform this activity. Therefore, the appropriate activity level assignment is "No assist."
D. Maximum assist means that the client needs physical assistance from two or more people to perform an activity.
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