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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. It acknowledges the client's emotions by expressing empathy ("I am sad for you") and offering support ("I'll stay with you for a while if you need to talk"). This approach validates the client's grief, acknowledges the significance of their loss, and offers the opportunity for the client to express their feelings if they choose to do so.
A. This can inadvertently minimize the client's grief by suggesting that the nurse's losses are comparable or that the nurse understands the client's emotions completely.
B. It does not acknowledge or validate the client's current emotions and may overlook the complex feelings associated with losing a parent.
C. This response, although intended to provide encouragement, may not be therapeutic in the context of immediate grief. It suggests a future positive outcome from the loss without acknowledging the client's current emotional pain.
Correct Answer is D
Explanation
D. A "thready" pulse is weak and difficult to palpate. It feels like a fine thread or string under the fingertips and suggests poor cardiac output or decreased peripheral perfusion. A thready pulse is palpable but weak, indicating inadequate stroke volume with each heartbeat.
A. Hypovolemic refers to a state of decreased blood volume, which can lead to a weak and rapid pulse due to reduced blood flow through the arteries. However, it does not specifically describe the quality of the pulse that is palpable.
B. Bradycardia refers to a slow heart rate, typically below 60 beats per minute in adults. A bradycardic pulse may be slow but can still be strong or weak depending on the underlying cause. It does not specifically describe the quality of a weak but palpable pulse.
C. "Deficient" is not a commonly used term to describe the quality of a pulse. It does not provide specific information about the palpable nature or strength of the pulse.
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