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 presence of a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor indicates the possibility of infection in the wound. Evaluating the client's C-reactive protein (CRP) level can provide information about the presence and severity of inflammation and infection. CRP is an acute-phase reactant produced by the liver in response to inflammation. An elevated CRP level suggests an active inflammatory process, which can help in determining the need for further assessment and treatment, such as wound cultures or antibiotics.
Here's why the other options are incorrect:
B- Serum blood glucose (BG) level: While diabetes and elevated blood glucose levels can increase the risk of infection and delay wound healing, in this case, the presentation of redness, swelling, drainage, and odor suggests a possible wound infection. Evaluating the client's blood glucose level is important for the overall management and control of diabetes, but it is not the first priority when assessing a potentially infected wound.
C- Serum albumin: Serum albumin is a measure of the client's nutritional status and can provide information about the client's overall protein levels. While malnutrition can affect wound healing, in this scenario, the priority is to assess for signs of infection and inflammation. Addressing the wound infection takes precedence over evaluating the client's serum albumin level.
D- Culture for sensitive organisms: Obtaining a wound culture for sensitive organisms may be necessary to identify the specific bacteria causing the infection and determine the appropriate antibiotic treatment. However, before performing a wound culture, it is important to assess the severity of the wound infection and determine the need for further intervention. Evaluating the client's CRP level is a more immediate and readily available assessment to determine the presence and severity of inflammation.
Correct Answer is ["B","E"]
Explanation
Correct:
B- Making these changes will also help me avoid other chronic health conditions. This statement indicates an understanding because the client recognizes that the lifestyle changes discussed will not only help prevent or manage diabetes but also have a positive impact on other chronic health conditions such as cardiovascular disease and obesity.
E- If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked. This statement indicates an understanding because the client acknowledges the importance of monitoring their blood sugar levels if they experience symptoms commonly associated with diabetes, such as increased thirst and urination.
Incorrect choices:
A- If my fasting blood sugar is less than 100 next time, I can go back to my usual eating habits. This statement indicates a misunderstanding. It suggests that as long as the client's fasting blood sugar is below 100, they can resume their previous eating habits, which is not accurate. It's important to emphasize that long-term lifestyle changes are necessary, regardless of individual blood sugar readings.
C- I can never eat sugar again. This statement indicates a misunderstanding. While it's important to minimize the consumption of sugary foods and beverages, it's not necessary to completely eliminate all sugar from the diet. Moderation and mindful consumption are key.
D- If I make the changes we talked about, I will not get type 2 diabetes. This statement indicates a misunderstanding. While making positive lifestyle changes can significantly reduce the risk of developing type 2 diabetes, it does not guarantee complete prevention. Genetic and other factors can still influence an individual's susceptibility to the condition.
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