A nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair. After securing a safe environment, what should the nurse do next?

Rock the patient up to a standing position.

Pivot on the foot that is the farthest from the chair.

Assess the patient for orthostatic hypotension.

Apply a gait belt to the patient.

Answer and Explanation

The Correct Answer is C

The correct answer is Choice C.

Choice C rationale: Assessing the patient for orthostatic hypotension is crucial because patients who can only bear weight on one leg may have compromised balance and stability. Orthostatic hypotension, or a sudden drop in blood pressure upon standing, could lead to dizziness or fainting, increasing the risk of falls and injury. Identifying this condition before transferring the patient ensures appropriate interventions can be taken to maintain safety and prevent accidents. The nurse can then apply necessary precautions such as additional support or slow, gradual position changes to minimize the risk.

Choice A rationale: Rocking the patient up to a standing position might help initiate the transfer, but it’s not the immediate priority after securing a safe environment. Ensuring the patient's stability and monitoring their vital signs, especially for orthostatic hypotension, is essential before attempting any movement.

Choice B rationale: Pivoting on the foot that is the farthest from the chair is part of the transfer technique, but it should only be performed after confirming the patient is stable and not at risk of orthostatic hypotension. Proper assessment precedes this step to prevent potential falls.

Choice D rationale: Applying a gait belt to the patient is important for safe transfer, but again, this step follows the assessment of the patient's condition. The gait belt is an aid for the transfer process, but its effectiveness relies on the patient's ability to stand without becoming dizzy or faint.

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Correct Answer is A

Explanation

Choice A rationale

The statement “What did I do to deserve this illness?” could indicate spiritual distress. This statement suggests that the patient may be struggling with feelings of guilt, punishment, or existential crisis, which are common manifestations of spiritual distress. The patient may be

questioning their moral or spiritual worth, or trying to find meaning or purpose in their suffering.

Choice B rationale

The statement “I blame medical science for not finding a cure” could indicate frustration or anger, but it does not necessarily indicate spiritual distress. While this statement suggests dissatisfaction with medical progress, it does not directly relate to the patient’s spiritual or existential concerns.

Choice C rationale

The statement “Where is my daughter when I need her most?” could indicate emotional distress related to the patient’s interpersonal relationships, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel abandoned or unsupported, but it does not directly relate to the patient’s spiritual or existential concerns.

Choice D rationale

The statement “Will I ever regain control over my life?” could indicate emotional distress related to the patient’s sense of autonomy and control, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel helpless or powerless in the face of their illness, but it does not directly relate to the patient’s spiritual or existential concerns.

A. Place a pillow under the patient’s knees. B. Position a trochanter roll under each of the patient’s hips. C. Advise the patient to wear rubber-soled slippers. D. Apply an ankle-foot orthotic device to the patient’s feet.

Correct Answer is D

Explanation

Choice A rationale

Placing a pillow under the patient’s knees can actually increase the risk of plantar flexion contractures by keeping the foot in a flexed position.

Choice B rationale

Positioning a trochanter roll under each of the patient’s hips would not directly prevent plantar flexion contractures. Trochanter rolls are typically used to maintain alignment and prevent external rotation of the hip.

Choice C rationale

Advising the patient to wear rubber-soled slippers would not directly prevent plantar flexion contractures. While rubber-soled slippers can provide safety benefits such as preventing slips and falls, they do not have a direct impact on the prevention of contractures.

Choice D rationale

Applying an ankle-foot orthotic device to the patient’s feet can help maintain the foot in a neutral position, thereby reducing the risk of developing plantar flexion contractures.

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A nurse is preparing to transfer a patient who can bear weight on one leg from the bed to a chair. After securing a safe environment, what should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

Explanation

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