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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Smokeless tobacco, such as chewing tobacco or snuff, still contains harmful substances, including nicotine and various chemicals. It is associated with several health risks, including an increased risk of oral, esophageal, and pancreatic cancers, as well as gum disease, tooth loss, and nicotine addiction.
Incorrect:
A. By providing this information, the nurse can help the client make an informed decision about their smoking cessation plan. It is crucial to emphasize that quitting tobacco altogether is the best approach to reduce the risk of cancer and improve overall health.
C. The nurse should not encourage the client to continue with the plan to switch to smokeless tobacco as a means of reducing the risk for cancer. Instead, the focus should be on supporting the client's efforts to quit tobacco entirely and providing appropriate resources and interventions to facilitate smoking cessation.
D. Addressing the concern about weight gain when quitting smoking is also important, but it should be done in the context of promoting healthy lifestyle changes and offering strategies to manage weight during the smoking cessation process.
Correct Answer is D
Explanation
Regular insulin is the medication of choice for treating DKA. Its main action is to lower blood glucose levels by promoting the uptake of glucose into cells and inhibiting the production of glucose by the liver. Therefore, checking the fingerstick blood glucose level is an important indicator of the effectiveness of the insulin treatment.
A decrease in the blood glucose level indicates that the insulin is working to lower the high blood sugar associated with DKA. This measurement helps the PN assess the response to treatment and adjust the insulin dosage if necessary.
The other actions mentioned are also important assessments in the care of a client with DKA, but they do not specifically evaluate the effectiveness of the insulin dosage:
A. Smelling the client's breath for resolution of a fruity odor is important as it indicates a decrease in ketone production, which is a marker of improving DKA. However, it does not directly evaluate the effectiveness of the insulin dosage.
B. Determining the client's orientation to time and space is part of assessing their neurological status, which is crucial in managing DKA. However, it does not specifically assess the effectiveness of the insulin dosage.
C. Measuring the client's urinary output for an increased volume is important to monitor hydration status and renal function, but it does not directly evaluate the effectiveness of the insulin dosage.
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