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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Related Questions
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.
Correct Answer is C
Explanation
A) The chair should be placed on the client's stronger (right) side to facilitate a safer and more controlled transfer. The client can use their stronger side to assist in the movement.
B) The bed should be at a comfortable height, ideally level with the chair, to allow a smooth transfer. Raising the bed too high can make it difficult for the client to place their feet firmly on the ground, reducing stability.
C) Locking the wheels on the bed ensures stability and prevents movement while assisting the client with the transfer. This is a crucial safety measure to reduce the risk of falls or injuries during the transfer process.
D) The chair should be positioned at a 45° angle to the bed to allow for a more natural pivot and smoother transfer. A 90° angle can make the movement more difficult and awkward for the client.
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