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 A
Explanation
A) Standing close to the object helps maintain better leverage and reduces strain on the back.
B) Keeping the feet apart provides a stable base of support when lifting heavy objects.
C) Twisting the spine can lead to injury; proper lifting involves keeping the spine aligned.
D) Bending at the hips and knees while keeping the back straight is the correct technique to avoid strain on the back.
Correct Answer is C
Explanation
A) This is part of proper body mechanics but not the first action when repositioning a client.
B) Proper body mechanics involve pivoting rather than twisting the spine but is not the first action when repositioning a client.
C) Adjusting the bed height ensures the nurse is working at an optimal level to prevent strain during the repositioning process.
D) Engaging core muscles is important for stability during lifting and repositioning but is not the first action to take.
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