A nurse is assisting in performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels?

Maximum assist

Minimal assist

Moderate assist

No assist

Answer and Explanation

The Correct Answer is B

A.   Maximum assist is when the client requires total assistance from one or more persons to perform the activity. In this scenario, the client is able to rise from a seated position
independently with the assistance of a cane, so maximum assist is not appropriate.
B.   Minimal assist is when the client requires some assistance or supervision to perform the activity but is able to complete most of the task independently. Since the client can rise from a seated position using a cane for support, they require minimal assistance.
C.   Moderate assist is when the client requires more help than minimal assist but can still contribute to the activity. Since the client can perform the task with minimal assistance, moderate assist is not appropriate.
D.   No assist is when the client is able to perform the activity without any assistance.
While the client uses a cane for support, they are still able to rise from a seated position independently, so no assist is not appropriate.

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Correct Answer is D

Explanation

A. Advancing the cane 12 inches forward when walking is not a standard instruction for cane use. Typically, the cane is advanced a short distance ahead of the individual's affected leg to provide support and stability during ambulation.
B. Holding the cane on the side of the affected leg does not provide adequate support and stability to the affected side while walking.
C. When climbing stairs, the cane should be held in the hand opposite the affected leg to provide support and balance. Placing the cane at the same level as the affected leg may
lead to imbalance and difficulty ascending stairs safely.

D. This is because when using a cane for ambulation, the cane should be held on the stronger side of the body, and the user should move the cane forward simultaneously with the affected (weaker) leg. Then, the stronger leg is moved forward, which helps in maintaining balance and stability during walking.

A. Orthostatic hypotension increases a client's risk of a fall. B. Orthostatic hypotension is indicated by a decrease in systolic blood pressure of 10 mm Hg. C. Orthostatic hypotension increases a client's risk of a pulmonary embolism. D. Orthostatic hypotension is indicated by a decrease in diastolic blood pressure of 5 mm Hg.

Correct Answer is A

Explanation

A. Orthostatic hypotension is characterized by a drop in blood pressure upon standing,
which can lead to dizziness or lightheadedness and increase the risk of falls, especially in older adults.
B. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg
within 3 minutes of standing up.

C. Orthostatic hypotension does not directly increase the risk of a pulmonary embolism.

A pulmonary embolism is a separate medical condition involving a blockage in one of the pulmonary arteries in the lungs.
D. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure, not diastolic blood pressure.

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A nurse is assisting in performing a mobility assessment on a client. The client can rise from a seated position using a cane for support. The nurse should assign the client which of the following activity levels?

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Naxlex Comprehensive Predictor Exams

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