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A nurse is preparing to reposition a client.
Which of the following actions should the nurse take first?

A.

Tighten their abdominal muscles.

B.

Raise the height of the client's bed.

C.

Pivot their feet in the direction of the move.

D.

Place their feet in line with their shoulders.

Answer and Explanation

The Correct Answer is D

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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Related Questions

Correct Answer is C

Explanation

Choice A rationale;

Inability to form healthy relationships: This is more commonly associated with fixation at the phallic stage.

Choice B rationale:

Feelings of shame are associated with Freud's psychosexual stages, particularly during the anal stage. Fixation at the oral stage is more likely to result in issues related to dependency and oral fixation, which may manifest as habits like nail-biting or smoking, rather than feelings of shame.

Choice C rationale:

According to Freud's psychosexual theory, fixation at the oral stage can lead to oral personality traits. These traits are often associated with oral activities like eating, drinking, smoking, and talking. Overeating is a common behavior linked to oral fixation, as it represents a seeking of oral gratification.

Choice D rationale:

Bedwetting is not typically associated with fixation at the oral stage of development. Bedwetting is more commonly linked to issues at the anal stage. In the oral stage, the fixation is primarily related to dependency and oral behaviors. .

Correct Answer is D

Explanation

The correct answer is d. "Seeing spots is a manifestation of diabetic retinopathy."

Choice A rationale:

  • Clouding of the lens is not a manifestation of diabetic retinopathy.It is a characteristic of cataracts,a condition that involves a different eye structure and has a different etiology.
  • Diabetic retinopathy specifically affects the retina,which is the light-sensitive tissue lining the back of the eye.It does not directly involve the lens.
  • It's crucial to clarify this distinction for the client to ensure accurate understanding of their condition and potential symptoms.

Choice B rationale:

  • Increased intraocular pressure is not the cause of diabetic retinopathy.It is the primary feature of glaucoma,another eye condition with distinct causes and consequences.
  • Diabetic retinopathy is primarily driven by damage to the blood vessels in the retina due to prolonged high blood sugar levels.
  • Explaining this difference to the client can help prevent confusion and promote appropriate preventive measures.

Choice C rationale:

  • While regular eye exams are essential for early detection and management of diabetic retinopathy,the recommended frequency is more often than every 2 years.
  • The American Diabetes Association recommends that individuals with diabetes have a comprehensive dilated eye exam at least annually.
  • More frequent exams may be necessary depending on the individual's risk factors and the severity of their diabetes.

Choice D rationale:

  • Seeing spots is a common and significant symptom of diabetic retinopathy.It occurs when blood vessels in the retina leak fluid or bleed,causing disruptions in vision.
  • Other potential symptoms of diabetic retinopathy include:
    • Blurred vision
    • Floaters (dark specks or strings that move across the visual field)
    • Difficulty seeing at night or in low light
    • Loss of central vision
    • Distortion of colors
    • Blind spots

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