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 ["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.
Correct Answer is C
Explanation
Choice A rationale
Reporting the APs to the charge nurse may seem like an appropriate action, but it does not directly address the conflict. It’s important for the nurse to take an active role in conflict resolution, rather than passing the responsibility to someone else.
Choice B rationale
Allowing the APs to resolve their issues might be a good idea in some situations, but it’s not the best choice here. As a nurse, it’s part of your role to ensure that conflicts are resolved in a way that promotes a positive and productive work environment. By simply allowing the APs to resolve their issues, you’re not taking an active role in conflict resolution.
Choice C rationale
Confronting the APs to discuss their argument is the best choice. This action demonstrates conflict resolution because the nurse is taking an active role in addressing the issue. By discussing the argument with the APs, the nurse can help them understand each other’s perspectives and find a solution that works for everyone.
Choice D rationale
Telling the APs they are acting immaturely is not an effective way to resolve conflict. This approach is likely to escalate the conflict rather than resolve it. It’s important to approach conflicts with a goal of understanding and resolution, rather than placing blame or making judgments.
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