A nurse is providing teaching with a client who has severe arthritis and has difficulty with stairs. What should the nurse include in the teaching?
"Keep your eyes on your feet when ascending or descending the stairs."
"Maintain your arms in a slightly bent position when using the handrails."
"Move your right leg forward as you lower yourself to the next step."
"Support yourself with the handrail when transferring to or from the stairs."
The Correct Answer is B
Choice A reason: This is not the correct answer because it distracts the client from the surroundings and could cause loss of balance or coordination.
Choice B reason: This is the correct answer because it enables the client to use the handrails as a support and reduces the stress on the arms and shoulders.
Choice C reason: This is not the correct answer because it creates an uneven distribution of weight and could cause instability or pain.
Choice D reason: This is not the correct answer because it requires the client to shift the body weight abruptly and could cause muscle strain or joint damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Client instructed on self-care needs is not a specific or accurate documentation. The nurse should include the details of the instruction, such as the topics covered, the teaching methods used, the client's response, and the evaluation of learning.
Choice B reason: Oral temperature elevated at 0800 is a specific and accurate documentation. The nurse should include the vital signs and any abnormal findings, such as fever, in the client's health record. The nurse should also report the elevation to the provider and monitor the client for signs of infection.
Choice C reason: Episiotomy approximated, 3 cm (1.18 in) in length is not a specific or accurate documentation. The nurse should include the type, location, and degree of the episiotomy, as well as the condition of the wound, the presence of edema, erythema, or drainage, and the interventions performed.
Choice D reason: Client drank adequate amounts of fluid with meals is not a specific or accurate documentation. The nurse should include the exact amount and type of fluid intake, as well as the output, in the client's health record. The nurse should also assess the client for signs of dehydration or fluid overload.
Correct Answer is D
Explanation
Choice A reason: Directing the partner to leave and return once postmortem care is complete is not respectful of the partner's feelings and wishes. The nurse should allow the partner to stay and participate in the postmortem care if they desire.
Choice B reason: Instructing the partner not to touch the client’s body is not compassionate or supportive of the partner's grief. The nurse should encourage the partner to touch, hold, or kiss the client’s body as a way of saying goodbye.
Choice C reason: Placing the client’s personal belongings in a safe location in the facility is a necessary action, but not the priority. The nurse should first ask the partner if they want to keep any of the belongings or give them to the nurse for safekeeping.
Choice D reason: Asking the partner about any rituals they would like to be performed is the most appropriate action. The nurse should respect and facilitate the partner's cultural, religious, or personal preferences for postmortem care.
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