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:
Establishing whether the client's grieving is healthy or complicated is the first step in the nursing process when caring for a client experiencing grief. This step falls under the assessment phase of the nursing process and is essential for understanding the client's needs and planning appropriate care.
Choice B rationale:
Developing client-specific goals and outcomes comes after the assessment phase in the planning stage of the nursing process. While important, it is not the first action the nurse should take in this situation.
Choice C rationale:
Incorporating the treatment into the client's care occurs during the implementation phase of the nursing process and follows assessment and planning. This is not the first action.
Choice D rationale:
Determining whether coping strategies were successful is part of the evaluation phase of the nursing process, which occurs after the implementation of care. It is not the first step in this situation. Now, let's proceed to the final question.
Correct Answer is D
Explanation
Choice A rationale:
Decreased thickness of tympanic membranes is not a typical physiological change in older adults. Tympanic membranes tend to become thinner and less flexible with age, leading to increased susceptibility to damage, not decreased thickness.
Choice B rationale:
Decreased tinnitus is not a physiological change related to aging. Tinnitus can occur in individuals of all ages and is often associated with various factors such as exposure to loud noises, ear infections, or underlying medical conditions.
Choice C rationale:
Decreased ear wax is not a typical physiological change in older adults. In fact, older adults may experience increased production of earwax, which can lead to hearing problems if not managed appropriately.
Choice D rationale:
Decreased ability to hear high-frequency sounds is a common physiological change in older adult clients. This change, known as presbycusis, is characterized by a reduced ability to hear high-pitched sounds due to changes in the inner ear, including damage to hair cells and changes in the auditory nerves. Presbycusis is a well-documented and expected age-related change in hearing.
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