A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

Postpone ADLS until an occupational therapist determines the client's abilities.

Eliminate daily care that is not essential for the client's recovery.

Inform the client of the time the ADLS will be performed.

Determine the client's preferences.

Answer and Explanation

The Correct Answer is C

A. Postpone ADLs until an occupational therapist determines the client's abilities. Delaying ADLs can lead to decreased independence and a decline in the client's physical condition. The nurse should assess the client's abilities and provide appropriate assistance.
B. Eliminate daily care that is not essential for the client's recovery. All aspects of daily care contribute to the client's overall well-being and quality of life. Eliminating non-essential care can negatively impact the client's mental and physical health.
C. Inform the client of the time the ADLs will be performed. Informing the client of the time the ADLs will be performed promotes consistency and allows the client to prepare mentally and physically. This helps maintain a routine, which can be reassuring for the client.
D. Determine the client's preferences. While it is important to consider the client's preferences, it is not the primary action. Informing the client of the schedule helps with planning and consistency.

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Correct Answer is D

Explanation

A. Saline lock (or peripheral intravenous lock) does not significantly increase the risk for falls by itself.
B. Prescribed mucolytic help loosen mucus but do not specifically increase fall risk.
C. Age 60 years or older can be a risk factor for falls due to changes in balance, strength, and coordination. However, the risk increases significantly with advanced age, making this a relevant factor to consider.
D. Diabetic neuropathy can impair sensation in the feet, increasing the risk of falls due to lack of awareness of foot position and potential injuries.

A. Overweight B. Extremely obese C. Normal D. Obese

Correct Answer is D

Explanation

To calculate the BMI:

Convert weight to kilograms: 90 kg (198 lb)
Convert height to meters: 160 cm = 1.6 m
Use the BMI formula: BMI = weight (kg) / height (m)^2

BMI = 90 / (1.6)^2 BMI = 90 / 2.56 BMI ≈ 35.2

A. Overweight: Overweight is typically classified with a BMI from 25 to 29.9. This BMI is higher.
B. Extremely obese: The term "extremely obese" is not commonly used. The classification for a BMI above 40 would be "extremely obese."
C. Normal: A normal BMI ranges from 18.5 to 24.9. The calculated BMI is higher than this range.
D. Obese: A BMI of 35.2 falls into the category of obesity (30 to 39.9).

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A nurse is caring for a client who requires partial assistance with ADLs. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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