A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

Walk on the client's right side.

Instruct the client to look down at their feet when ambulating.

Have the client sit on the side of the bed for at least 60 seconds before ambulating.

Place the gait belt securely around the client's lower chest.

Answer and Explanation

The Correct Answer is C

The correct answer is C.

Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.

Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.

Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.

Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.

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Correct Answer is D

Explanation

Choice A rationale:

Dysrhythmia refers to irregular heart rhythms and is not associated with the carotid artery. It involves issues with the heart's electrical conduction system.

Choice B rationale:

A cardiac murmur is an abnormal sound heard during the heartbeat cycle, usually indicating turbulent blood flow across heart valves. It's not directly related to the carotid artery.

Choice C rationale:

Hypotension refers to low blood pressure, which might impact blood flow through the carotid artery but wouldn't directly cause the sound known as a bruit.

Choice D rationale:

A bruit heard while auscultating the carotid artery suggests a narrowed arterial lumen. A bruit is a whooshing or blowing sound caused by turbulent blood flow due to arterial narrowing or blockage.

A. Provide a cup of hot chocolate prior to bedtime. B. Schedule exercise activities at least 3 hr before bedtime. C. Keep soft music playing at bedtime and throughout the night. D. Schedule mealtime 2 hr before bedtime.

Correct Answer is B

Explanation

Choice A rationale:

Providing a cup of hot chocolate prior to bedtime is not a suitable intervention for a client reporting difficulty sleeping. Hot chocolate contains caffeine, which can act as a stimulant and interfere with sleep. Caffeine is known to disrupt sleep patterns and should be avoided close to bedtime.

Choice B rationale:

Scheduling exercise activities at least 3 hours before bedtime is the correct intervention for a client experiencing difficulty sleeping. Regular exercise promotes better sleep quality by helping to regulate the sleep-wake cycle and improve sleep duration. However, exercising too close to bedtime can have a stimulating effect, making it harder for the client to fall asleep. By scheduling exercise activities earlier in the day, the client's body will have sufficient time to wind down before bedtime, leading to improved sleep.

Choice C rationale:

Keeping soft music playing at bedtime and throughout the night might not be effective for everyone. While soft music can create a calming environment and help some individuals relax, it may not address the underlying causes of the client's difficulty sleeping. Additionally, some people might find background noise disruptive to their sleep. Therefore, this option might not be as effective as adjusting the timing of exercise.

Choice D rationale:

Scheduling mealtime 2 hours before bedtime is generally a good practice, but it might not directly address the client's reported difficulty sleeping. Consuming heavy or spicy meals close to bedtime can cause discomfort and indigestion, which might interfere with sleep. However, adjusting mealtime alone might not be sufficient to resolve the client's sleep issues, especially if other factors are contributing to their insomnia.

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A nurse is planning to assist a client who has left-sided weakness to ambulate using a gait belt. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is auscultating a client's carotid artery while performing a focused cardiac assessment and hears a bruit. The nurse should identify this finding as a manifestation of which of the following conditions?

Correct Answer is D

Explanation

A nurse is planning care for a client who reports having difficulty sleeping. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

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