A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

Demonstrate to the client how to use the signaling device.

Explain the facility's meal schedule

Demonstrate to the client how to use the television.

Explain the medication administration schedule.

Answer and Explanation

The Correct Answer is A

A. Demonstrate to the client how to use the signaling device: Teaching the client how to use the call light is the priority because it ensures they can easily ask for assistance, especially with limited mobility. Immediate access to help reduces the risk of falls, injury, and delays in meeting urgent needs.

B. Explain the facility's meal schedule: While it is important for the client to know when meals are served, this information does not impact their immediate safety or ability to get assistance when needed, making it a lower priority than teaching about the call light.

C. Demonstrate to the client how to use the television: Teaching about the television promotes comfort but is nonessential for safety or urgent needs. Comfort measures can be addressed after critical safety interventions have been completed.

D. Explain the medication administration schedule: Understanding medication schedules is important for client education and adherence, but ensuring the ability to call for help is more immediately critical, especially in a client with limited mobility.

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Correct Answer is A

Explanation

A. Powered-standing assist lift: A powered-standing assist lift is appropriate for a cooperative client with upper body strength who is non-weight bearing. It allows the client to participate by supporting themselves with their arms while the device safely moves them from the bed to a chair without bearing weight on their lower extremities.

B. Draw sheet: A draw sheet is typically used for repositioning a client in bed, not for transferring them from bed to chair. It does not provide the mechanical support needed to lift and transfer a non-weight-bearing client safely.

C. Gait belt: A gait belt is useful for clients who can bear weight to some degree and require minimal assistance during transfers. Since this client is non-weight-bearing, a gait belt alone would not provide adequate support and could lead to injury.

D. Full body sling lift: A full body sling lift is used for clients who are non-weight bearing and lack the ability to assist in transfers. Since the client described here is cooperative and has upper body strength, a full sling would not be necessary and may restrict their participation.

A. "I really wish I had a girl instead." B. "I am so relieved the baby looks like my mother." C. "My labor was so long I'm glad it's over." D. "My appetite has really increased”

Correct Answer is A

Explanation

A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.

B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.

C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.

D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.

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A nurse is assisting with the admission of a client who has limited mobility. Which of the following actions is the nurse's priority?

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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