An older postoperative client has the nursing problem, "Impaired mobility related to fear of falling." Which desired outcome best directs the practical nurse's (PN) actions for this client?

The client will use self-affirmation statements to decrease fear.

The client will ambulate with assistance for q4 hours.

The physical therapist will instruct the client in the use of a walker.

The PN will place a gait belt on the client prior to ambulation.

Answer and Explanation

The Correct Answer is B

While all of the options address the issue of impaired mobility related to fear of falling, the desired outcome of ambulating with assistance q4 hours is the most specific and measurable goal. This outcome focuses on promoting mobility and addressing the client's fear of falling by providing the necessary assistance during ambulation. It ensures that the client is engaging in regular activity and working towards regaining mobility.
The other options address different aspects of the nursing problem:

A. "The client will use self-affirmation statements to decrease fear" is a potential intervention that can be used to address the client's fear of falling, but it does not directly address the issue of impaired mobility.
C. "The physical therapist will instruct the client in the use of a walker" is an intervention that can be helpful in improving mobility, but it does not specify the frequency or timing of ambulation.
D. "The PN will place a gait belt on the client prior to ambulation" is a specific intervention that ensures the safety of the client during ambulation, but it does not address the frequency or timing of ambulation.

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Correct Answer is D

Explanation

A: This response is inappropriate as it can be seen as encouraging or validating the patient's comment, which is not professional behavior in a healthcare setting.
B: This choice might seem like a deterrent, but it is more punitive than educational. It does not address the inappropriateness of the comment or guide the patient to understand why the comment was unacceptable.
C: While this statement is true, it does not provide guidance to the patient on appropriate communication. It may also come across as dismissive and does not address the need for respectful interaction.
D: This is the correct response because it sets clear boundaries and communicates to the patient that such comments are not acceptable. It is important for healthcare professionals to maintain a professional environment and educate patients about appropriate behavior.

A. Health care proxy documentation. B. Name of funeral home to contact. C. Client's wishes regarding organ donation. D. Contact information for the client's next of kin.

Correct Answer is A

Explanation

- A terminally ill client is a client who has a progressive and incurable disease or condition that is expected to result in death within a short period of time, such as months or weeks. A terminally ill client may require palliative care, which is the care that focuses on relieving pain and suﬀering and improving the quality of life for the client and their family.
- An admission assessment is the process of collecting information about a client's health status, needs, preferences, and goals when they are admitted to a health care facility, such as a hospital, nursing home, or hospice. An admission assessment helps to establish a baseline for the client's condition, plan and implement appropriate interventions, and evaluate the outcomes of care.
- A health care proxy is a legal document that allows a client to appoint another person, such as a family member or a friend, to make health care decisions for them if they become unable to do so themselves. A health care proxy may also include specific instructions or preferences about the type and extent of care that the client wishes to receive or refuse, such as life-sustaining treatments, resuscitation, or organ donation.
- Health care proxy documentation is important information that the practical nurse (PN) should collect during the admission assessment of a terminally ill client to an acute care facility, as it reﬂects the client's autonomy, dignity, and wishes regarding their end-of-life care. It also helps to ensure that the client's healthcare decisions are respected and followed by the healthcare team and the facility.

- Therefore, option A is the correct answer, while options B, C, and D are incorrect.

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An older postoperative client has the nursing problem, "Impaired mobility related to fear of falling." Which desired outcome best directs the practical nurse's (PN) actions for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "WOW! You have big breasts." Which response is best for the PN to provide?

Correct Answer is D

Explanation

Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

Correct Answer is A

Explanation

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