After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?
Offer a pair of non-skid socks.
Place the chair by the bed.
Support the client when rising.
Determine how the client feels.
The Correct Answer is C
Choice A reason: Offering a pair of non-skid socks is not the most important action to implement next. The client may already have non-skid socks on, or may not need them if they are not walking. The priority is to prevent falls and injuries when transferring the client to the chair.
Choice B reason: Placing the chair by the bed is a necessary action to implement, but not the next one. The chair should already be by the bed before the nurse raises the head of the bed and moves the client to a sitting position. The next action is to help the client stand up and move to the chair.
Choice C reason: Supporting the client when rising is the best action to implement next. The client may be weak, dizzy, or unsteady after a week of bedrest, and may need assistance to stand up and sit down. The nurse should use proper body mechanics and a transfer belt if needed to support the client.
Choice D reason: Determining how the client feels is a relevant action to implement, but not the next one. The nurse should assess the client's vital signs, comfort, and tolerance of the activity after transferring the client to the chair. The next action is to ensure the client's safety and stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct action because the nurse should provide realistic expectations and positive reinforcement to the client. Lifestyle changes such as exercise can improve sleep quality and duration, but they may not have immediate effects. The nurse should encourage the client to continue the workout program and follow good sleep hygiene practices.
Choice B reason: This is not the best action because the nurse should focus on the client's sleep problem rather than the weight loss goal. While weight loss can be a benefit of exercise, it is not the primary reason why the client started the workout program. The nurse should not make the client feel that weight loss is the only measure of success.
Choice C reason: This is also not the best action because the nurse should not interrogate the client about the details of the exercise schedule. The nurse should respect the client's autonomy and preferences regarding physical activity. The nurse can offer suggestions or resources to help the client optimize the exercise schedule, but should not imply that the client is doing something wrong.
Choice D reason: This is another incorrect action because the nurse should not encourage the client to exercise every day or close to bedtime. Exercising too frequently or too late can interfere with the body's circadian rhythm and cause sleep problems. The nurse should advise the client to exercise at least three times a week and avoid exercising within three hours of bedtime.
Correct Answer is A
Explanation
Choice A reason: This is the best explanation as it describes the main goal of the log-rolling technique, which is to prevent twisting or bending of the spine. This is especially important for clients who have spinal injuries, surgeries, or disorders.
Choice B reason: Using two or three people is a part of the log-rolling technique, but it is not the purpose of it. It is a means to achieve the purpose of maintaining spinal alignment. It also ensures that the client is moved smoothly and gently.
Choice C reason: Working together can decrease the risk of back injury to the nurses, but it is not the purpose of the log-rolling technique. It is a benefit for the nurses, but not for the client. The nurse should focus on the client's needs and outcomes.
Choice D reason: Turning instead of pulling reduces the likelihood of skin damage, but it is not the purpose of the log-rolling technique. It is an advantage for the client, but not the main reason for using the technique. The nurse should explain how the technique affects the spine, not the skin.
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