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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Keep the client's personal items within reach.Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.
Incorrect options:
A. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.
B. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.
D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.
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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