A nurse is conducting a mobility assessment on a patient.
The patient can stand up from a seated position using a cane for support.
Which of the following activity levels should the nurse assign to the patient?
Minimal assistance
Moderate assistance
No assistance
Maximum assistance
Maximum assistance
The Correct Answer is C
Choice A rationale
Minimal assistance implies that the patient needs some help but can do most of the task on their own. In this case, the patient is able to stand up from a seated position using a cane for support, which suggests that they do not need assistance.
Choice B rationale
Moderate assistance implies that the patient needs more help to perform the task. The patient in the scenario is able to perform the task independently with the help of a cane.
Choice C rationale
No assistance means that the patient can perform the task independently. This is the most fitting answer because the patient is able to stand up from a seated position using a cane for support.
Choice D rationale
Maximum assistance implies that the patient is unable to perform the task without substantial help. This does not apply to the patient in the scenario as they are able to stand up independently with the help of a cane.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While hypertension is a risk factor for stroke, it is a modifiable risk factor. This means it can be controlled and managed through lifestyle changes and medication.
Choice B rationale
Family history is a non-modifiable risk factor for stroke. If a close family member, like a parent or sibling, has had a stroke, a person’s risk of stroke is slightly higher.
Choice C rationale
Smoking is a modifiable risk factor for stroke. Quitting smoking can significantly reduce the risk of stroke.
Choice D rationale
Obesity is a modifiable risk factor for stroke. Maintaining a healthy weight through diet and regular exercise can help reduce the risk of stroke.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Slow capillary refill is a sign that the body is not circulating blood as effectively as it should be. This can be a sign that a person is actively dying.
Choice B rationale
Ringing in the ears, also known as tinnitus, is not typically a sign that a person is actively dying. It can be caused by a variety of factors, including exposure to loud noise, certain medications, and some health conditions.
Choice C rationale
Cold hands and feet can be a sign that a person is actively dying. As the body’s systems start to shut down, blood flow to the extremities can decrease, causing them to feel cold.
Choice D rationale
Mottled and blotchy skin, especially on the hands, feet, and knees, can be a sign that a person is actively dying. This is caused by reduced blood flow to the skin.
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