A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

Powered stand assist

Cane

Gait belt

Four wheel walker

Answer and Explanation

The Correct Answer is C

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

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Correct Answer is C

Explanation

A. "Tell me about your support system at home." This is an open-ended, therapeutic question that encourages the patient to discuss their support network.

B. "What treatment options has your doctor spoken with you about?" This is an appropriate way to assess the patient's understanding of their diagnosis and plan of care.

C. “I am sure you are scared. Everything will be okay." This statement is nontherapeutic because it offers false reassurance and dismisses the patient’s emotions rather than acknowledging their concerns.

D. "This must be a hard time for you. How are you coping?" This is an empathetic statement that acknowledges the patient's feelings and invites them to express their emotions.

A. Check the patient's urinalysis. B. Notify the provider of the patient's pain 7/10 C. Perform a bladder scan D. Assess the daily weight.

Correct Answer is C

Explanation

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

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A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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