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 C
Explanation
Choice A rationale:
An increase in skin thinning is not a typical age-related change in the skin. In older adults, skin tends to become thinner due to a decrease in subcutaneous tissue, making it more fragile and susceptible to damage.
Choice B rationale:
An increase in skin elasticity is not a common characteristic of aging skin. In fact, older adults often experience a decrease in skin elasticity, leading to wrinkles and sagging skin.
Choice D rationale:
While there may be changes in blood supply to the skin as people age, an increase in blood supply is not a well-established or typical age-related change. Decreased blood flow to the skin is more common in older adults.
Choice E rationale:
Decrease in skin hydration is a common age-related change, but it's not the most significant change mentioned in the question. The primary focus in older adults is the decrease in subcutaneous tissue, which has a more direct impact on skin health.
Correct Answer is D
Explanation
Choice A rationale:
Increasing the heat in the client's room is not the appropriate action for managing dyspnea. Dyspnea, or difficulty breathing, is not typically related to room temperature. Other interventions should be prioritized.
Choice B rationale:
Performing nasotracheal suctioning for the client is not the initial action to address dyspnea at the end of life. Suctioning is indicated when there is excessive secretions or airway obstruction but should not be the first intervention for dyspnea.
Choice C rationale:
Placing the head of the client's bed flat is not the best action for a client experiencing dyspnea. Elevating the head of the bed (Fowler's position) is the recommended position to improve lung expansion and reduce dyspnea in clients with breathing difficulties.
Choice D rationale:
Administering an opioid narcotic to the client is the most appropriate action for managing dyspnea at the end of life. Opioid medications, such as morphine, are often used to relieve severe dyspnea in hospice and palliative care settings. These medications can help relax the client and reduce the sensation of breathlessness. .
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