A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?

Elevates the client's legs before applying the stockings

Instructs the client to dorsiflex their feet while applying the stockings

Massages the client's legs before applying the stockings

Folds the top of the stockings over after applying them

Answer and Explanation

The Correct Answer is A

A. Elevating the client's legs before applying the stockings helps reduce venous stasis by promoting venous return and decreasing edema, which is essential for the effectiveness of the stockings.

B. Dorsiflexion of the feet can also aid in the application but is not as critical as elevation.

C. Massaging the legs is contraindicated as it may dislodge clots if present.

D. Folding the top of the stockings over can create a tourniquet effect and impede blood flow, which is harmful to the client.

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Correct Answer is D

Explanation

A. While reminders of behavioral expectations can be helpful, excessive verbal guidance may increase frustration and is less effective than physical outlets for excess energy.
B. Group activities can be overstimulating for a client experiencing mania and may escalate agitation or distractibility.
C. Allowing unrestricted clothing choices is not a priority intervention during mania and does not address safety or energy management.
D. Encouraging the client to increase physical activity provides a safe outlet for excessive energy, reduces tension, and helps prevent injury or destructive behaviors. Structured physical activity is a therapeutic strategy during manic episodes.

A. Check the client's ability to use the call light. B. Document the client's risk in the medical record. C. Request a referral for physical therapy. D. Place a gait belt in the client's room.

Correct Answer is A

Explanation

A. "Check the client's ability to use the call light." This is the first action to take because ensuring the client can call for assistance if needed is crucial for their safety. If the client has impaired mobility and is at risk for falls, they should be able to summon help easily if they need to move or if assistance is required.

B. "Document the client's risk in the medical record." While documentation is important, ensuring the client can call for help should be prioritized to address immediate safety needs. Documenting the risk can occur after addressing immediate needs.

C. "Request a referral for physical therapy." While physical therapy may be indicated later, the priority is to ensure the client’s immediate safety by confirming they can call for help if needed.

D. "Place a gait belt in the client's room." A gait belt can be useful for assisting with mobility, but the immediate concern is ensuring the client can call for help if they need it, rather than preparing for assistance with mobility.

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A nurse is observing an assistive personnel (AP) apply antiembolic stockings for a client. The nurse should identify that which of the following actions by the AP indicates an understanding of the procedure?

Nursing Test Bank

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