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 A
Explanation
A. The first priority in any emergency situation is to ensure personal safety. The nurse should immediately walk to a safe area, away from the smoke and potential danger,
before taking further action.
B. While closing doors can help contain smoke and fire, personal safety takes
precedence. The nurse should prioritize evacuating to a safe location before attempting to close doors.
C. Wrapping clients in blankets may not be appropriate in this situation, as it does not address the immediate threat posed by the smoke and potential fire. Ensuring personal safety is the priority.
D. While staying close to the ground can reduce exposure to smoke and toxic fumes in some situations, it is not the first action to take. Evacuating to a safe area is the most
important step to protect oneself from harm.
Correct Answer is C
Explanation
A. The list of medications is typically included in the Background component of the ISBARR communication tool, as it provides important information about the client's ongoing treatment and medications.
B. Treatment plans and interventions are generally discussed in the Assessment and Recommendation components of the ISBARR communication tool, as they involve the nurse's assessment of the client's condition and the actions recommended for continued care.
C. The Situation component of the ISBARR communication tool focuses on providing a concise summary of the client's current medical condition or status, including relevant changes since the last report or significant events that occurred during the shift.
D. Vital signs may be included as part of the Background or Assessment components of the ISBARR communication tool, depending on their relevance to the client's current condition and any changes observed during the shift.
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