A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?
Check that the client lifts the walker and then places it down in front of her.
Walk in front of the client to guide her in moving the walker.
Have the client move one leg forward with the walker.
Make sure that the upper bar of the walker is level with the client’s waist.
The Correct Answer is A
A. Check that the client lifts the walker and then places it down in front of her.
To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.
B. Walk in front of the client to guide her in moving the walker.
The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.
C. Have the client move one leg forward with the walker.
The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.
D. Make sure that the upper bar of the walker is level with the client’s waist.
The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “I wish I didn’t have to attach the electrodes to my skin.”
This statement reflects a common sentiment. Attaching electrodes to the skin is part of using TENS, and it's a non-invasive procedure where electrodes are placed on the skin surface to deliver electrical impulses for pain relief.
B. “It’s unfortunate that I have to be in the hospital for this treatment.”
This statement indicates a need for further teaching. TENS is typically an outpatient treatment, and individuals can use TENS units at home after receiving appropriate instructions and training. It does not require being in the hospital.
C. “I’ll need to shave the hair off the skin where I place the electrodes.”
This statement is accurate. To ensure proper contact and effectiveness, it is often recommended to shave or trim the hair in the area where the electrodes will be placed.
D. “I hope I don’t have to take as many pain pills.”
This statement reflects an understanding of the potential benefits of TENS. TENS is used as an adjunct therapy to help manage pain, and one of its goals may be to reduce the need for pain medications.
Correct Answer is C
Explanation
A. To help the nurse validate the client’s reports of pain
This option suggests that the nurse's actions (straightening bed linens, rubbing the back, assisting with repositioning) are intended to assess or confirm the client's reports of pain. However, these actions are more aligned with providing comfort and assistance with activities of daily living rather than specifically assessing pain. If the client reports pain related to the chest tube, a more focused assessment and intervention would be needed.
B. To increase positive pressure in the chest
This option implies that the nurse's actions could somehow influence the positive pressure in the client's chest, which is not accurate. Positive pressure in the chest is usually related to mechanical ventilation or specific medical interventions. The described actions are more related to comfort and assistance with daily activities.
C. To assist the client with ADLs (Activities of Daily Living)
This is the most appropriate choice. The nurse's actions, such as straightening bed linens, rubbing the back, and assisting with repositioning, align with providing support for the client's daily activities and overall well-being.
D. To modify the client’s perception of pain
This option suggests that the nurse's actions are aimed at altering the client's perception of pain. While comfort measures can contribute to pain management, these specific actions are not typically used to modify perception. If pain is a concern, more direct pain management strategies and assessments would be appropriate.
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