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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. High-Fowler:
In the high-Fowler position (sitting upright at 60-90 degrees), gravity pulls the client downward, making it more difficult to reposition them toward the head of the bed.
B. Lateral:
In the lateral position (lying on the side), the client is not aligned for upward movement and would require additional steps to turn them back to a supine position before repositioning.
C. Prone:
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The prone position (lying on the stomach) is not appropriate for repositioning toward the head of the bed, as it makes movement more difficult and increases the risk of injury.
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D. Supine:
This position provides a stable and neutral alignment for the client's body, making it easier to use safe lifting techniques or assistive devices (e.g., draw sheet) to move the client toward the head of the bed.
Correct Answer is D
Explanation
A) Urine retention is a common symptom of bladder outlet obstruction but in this case assessing the patient for a urinary tract infection is the priority.
B) While proteinuria can indicate kidney dysfunction, it's not directly related to urinary retention.
C) This refers to bladder dysfunction due to neurological causes and may not be directly related to urinary retention in an immobile client.
D) Immobility can increase the risk of urinary tract infections Urinary retention can lead to urinary tract infection (UTI) due to bacterial growth in the stagnant urine. The nurse should monitor the client for signs and symptoms of UTI, such as fever, chills, dysuria, hematuria, and foul-smelling urine.
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