A nurse is performing a mobility assessment on a client.
Which of the following actions should the nurse take first?
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 stand for 5 seconds.
Ask the client to march in place.
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Secondary prevention involves early detection and intervention to prevent the progression of a disease. In the case of breast cancer, a mammogram is a secondary prevention measure because it aims to detect cancer at an early stage, especially in individuals with a family history of the disease. Early detection can lead to timely treatment and improved outcomes.
Choice B rationale:
Echocardiograms are typically used to assess the function of the heart and diagnose existing heart conditions. While it is a valuable diagnostic tool, it is not an example of secondary prevention, which is focused on early detection and prevention of disease.
Choice C rationale:
Influenza vaccination is an example of primary prevention, as it aims to prevent the initial occurrence of the disease by providing immunity against the influenza virus. It is not considered a form of secondary prevention.
Choice D rationale:
Not scheduling a series of tests for an asymptomatic client does not fit the definition of secondary prevention. Secondary prevention involves screening and early detection in individuals at risk or with early signs of a disease to prevent its progression. An asymptomatic client without known risk factors may not require such testing as a preventive measure.
Correct Answer is
Explanation
Choice A rationale:
Constipation in a client on bedrest is a common issue, and one of the primary interventions is to increase fluid intake. Adequate hydration helps soften the stool, making it easier to pass, and can prevent constipation. This intervention is based on sound nursing principles and is the most appropriate choice.
Choice B rationale:
Encouraging the client to drink cold fluids is not a specific intervention for constipation. While staying hydrated is important, the temperature of the fluids is not as relevant to relieving constipation as the overall fluid intake.
Choice C rationale:
Requesting a prescription for mineral oil is not the first-line intervention for constipation. Mineral oil can have potential side effects and should only be used when other measures have failed. Increasing fluid intake and dietary fiber are typically the initial steps taken.
Choice D rationale:
Placing the client on a low-fiber diet is not an appropriate intervention for constipation. A low-fiber diet can exacerbate constipation by reducing the bulk and softness of the stool. This choice is counterproductive to addressing the issue.
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