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) Orthostatic hypotension primarily affects blood pressure regulation and is not directly related to the risk of pulmonary emboli.
B) Orthostatic hypotension can cause dizziness and fainting upon standing, increasing the risk of falls.
C) Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of 20 mm Hg or more.
D) Orthostatic hypotension is primarily diagnosed based on changes in systolic blood pressure, not diastolic blood pressure.
Correct Answer is ["A","B","C","E"]
Explanation
A) HAIs, are infections that clients acquire while receiving health care services in any setting, such as hospitals, clinics, or home care agencies. Ventilator-associated pneumonia is a common HAI.
B) Catheter-associated urinary tract infections are a common HAI.
C) Surgical site infections are a common HAI.
D) A client who has influenza acquired from a coworker is not an example of an HAI, because the infection was not related to the health care services they received.
E) Central line-associated bloodstream infections are a common HAI.
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