The nurse is teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?
Ask the patient to try to stand up independently to assess the patient's strength first.
Remind the patient to look up to ensure good positioning when standing up.
Allow the patient to dangle at the edge of the bed before standing to assess for feelings of dizziness.
Assess the patient for any numbness or tingling in the extremities.
The Correct Answer is A
A. Ask the patient to try to stand up independently to assess the patient's strength first. This action is inappropriate as it may put the patient at risk of falling or injury. The patient should be assisted rather than asked to stand independently.
B. Remind the patient to look up to ensure good positioning when standing up. This is a correct action. Looking up helps the patient maintain better posture and balance when standing.
C. Allow the patient to dangle at the edge of the bed before standing to assess for feelings of dizziness. This is appropriate as it helps to identify any dizziness or orthostatic hypotension before the patient attempts to stand.
D. Assess the patient for any numbness or tingling in the extremities. This is also appropriate as it helps to identify any neurological issues that could affect the patient's ability to stand and transfer safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Meeting friends for fast food daily. This option does not promote joint mobility or health and could lead to poor overall health.
B. Running 5 miles daily in a safe, well-lit area. While running can improve cardiovascular health, it may not be appropriate for an elderly person due to the risk of joint and injury.
C. Exercising 2 hours each day in a gym. Excessive exercise can lead to injury, particularly in the elderly. Moderation and appropriate exercise are crucial.
D. Walking on a lunch break with a friend in a safe area. Regular walking is a low-impact exercise that promotes joint mobility and overall health, making it a suitable choice for an elderly person.
Correct Answer is A
Explanation
A. Lateral heels offloaded with pillows: Positioning the patient laterally with heels offloaded helps reduce pressure on the heels and prevent pressure sores.
B. Supine heels offloaded with pillows: Although offloading the heels is important, the supine position may still exert pressure on the heels and does not provide as effective offloading as the lateral position.
C. Fowler's heels offloaded with pillows: Fowler’s position may still place some pressure on the heels, even with pillows for offloading.
D. Prone ankles offloaded with pillows: The prone position is generally not recommended for patients with spinal injuries, and it does not effectively address heel pressure.
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