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 A
Explanation
The finding that is the highest priority for the PN to report to the charge nurse is the blood urea nitrogen (BUN) level of 75 mg/dL or 12.9 mmol/L. This result indicates an elevated BUN level, which can be indicative of impaired kidney function. In a client receiving chemotherapy, an elevated BUN level may suggest chemotherapy-induced nephrotoxicity or other kidney-related complications. Prompt reporting is crucial to ensure appropriate intervention and management of the client's kidney function.
B. While the platelet count of 135,000/mm3 or 135 x 109/L is slightly below the normal reference range, it does not pose an immediate life-threatening risk. However, it should still be monitored and reported to the healthcare team for ongoing assessment and evaluation.
C. Decreased deep tendon reflexes may be an expected side effect of certain chemotherapy medications or a manifestation of neurotoxicity. While this finding should be documented and monitored, it is not as urgent as the elevated BUN level.
D. Periodic nausea and vomiting are common side effects of chemotherapy, but they may also be indicative of other underlying issues such as dehydration, electrolyte imbalances, or gastrointestinal complications. While this finding should be addressed and managed, it is not the highest priority compared to the elevated BUN level.
Correct Answer is B
Explanation
A. Asking the client if she has previously been catheterized is important for understanding her history and comfort level but is not the first action to take in preparation for the procedure.
B. Consulting with the charge nurse about the catheter may be appropriate if there are concerns about the catheter type, but it is not a priority before starting the procedure.
C. Obtaining a 30 mL syringe and a vial of sterile water is essential for inflating the balloon after catheter insertion, but this can be done after positioning the client.
D. Positioning the client and observing the urinary meatus is the first action the PN should take. This step ensures the client is comfortable and provides a clear view for proper catheter insertion, which is crucial for the procedure's success.
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