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 B rationale:
Acute pain is typically associated with a sudden injury or condition, and it is usually short-term and self-limiting. Phantom limb pain is a chronic condition that is often neuropathic in nature.
Choice C rationale:
Cancer pain is generally associated with the presence of a tumor or cancer-related treatment. Phantom limb pain is not directly related to cancer.
Choice D rationale:
Chronic pain is a broad category that includes various types of long-lasting pain, but in the case of phantom limb pain, it is specifically neuropathic in nature. Neuropathic pain originates from damage or dysfunction of the nervous system and is a common characteristic of phantom limb pain. .
Correct Answer is D
Explanation
Choice A rationale:
Tightening abdominal muscles is not the first action the nurse should take when repositioning a client. Repositioning a client requires proper body mechanics and coordination. Tightening abdominal muscles may not be as effective or safe as other actions in ensuring the client's safety during repositioning.
Choice B rationale:
Raising the height of the client's bed is not the first action the nurse should take when repositioning a client. Adjusting the bed height is a secondary consideration and can be done after ensuring proper body mechanics and patient safety during the repositioning process.
Choice C rationale:
Pivoting the feet in the direction of the move is a crucial step when repositioning a client. This action allows the nurse to maintain balance and control during the transfer. It also reduces the risk of injury to the nurse and the client. However, it is not the first action to be taken.
Choice D rationale:
Placing the feet in line with the shoulders is the first action the nurse should take when repositioning a client. This wide base of support provides stability and balance. It allows the nurse to maintain control during the repositioning process, reducing the risk of injury to both the nurse and the client. After achieving this stable stance, pivoting the feet in the direction of the move is the next step to facilitate the repositioning.
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