The nurse will be assisting the client to walk. What should the nurse do first?

Assist the client to a sitting position at the side of the bed

Determine the client's strength, coordination, and activity tolerance

Help the client into a standing position

Ask another nurse for assistance

Answer and Explanation

The Correct Answer is B

B. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.

A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.

C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.

D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.

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Correct Answer is B

Explanation

B. This is the initial phase of the nurse-client relationship where the individuals first meet. It is characterized by establishing rapport, clarifying roles, setting goals, and developing an agreement or contract for the relationship.

A. This phase occurs towards the end of the nurse-client relationship when goals have been achieved or the relationship is ending for other reasons. It involves summarizing, evaluating progress, and saying goodbye.

C. This phase follows the orientation phase. It is characterized by actively working together to achieve mutually agreed upon goals. During this phase, the nurse and client explore issues, develop and implement solutions, and evaluate progress towards goals.

D. This phase occurs before the nurse and client meet formally. It involves gathering information about the client from various sources, such as medical records or other healthcare professionals.

A. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens. B. Client fell out of bed, but did push the call button for assistance. C. Recorder responded to client's call light, upon entering the room, found client on floor D. Client became tangled in the bed linens, then called for assistance after falling out of bed.

Correct Answer is C

Explanation

C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.

A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.

B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.

D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.

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The nurse will be assisting the client to walk. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The phase of the nurse-client relationship that begins when the individuals first meet, and that is characterized by an agreement to continue meeting and assessing needs is the:

Correct Answer is B

Explanation

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?

Correct Answer is C

Explanation

The nurse is assessing internal variables that influence a client's health care beliefs and practices. As part of this assessment, the nurse should consider the client's:

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