A nurse is collecting data on the mobility of a client. Which of the following actions should the nurse take first?
Ask the client to stand for 5 seconds.
Ask the client to place their feet on the floor.
Ask the client to sit on the edge of the bed for 2 min.
Ask the client to march in place.
The Correct Answer is C
A) Standing requires more mobility and strength; it's not the first step in assessing mobility.
B) Placing feet on the floor assesses the client's ability to follow instructions and indicates readiness for further mobility assessments but is not the first step compared to sitting on the edge of the bed for 2 minutes.
C) This is the first action that the nurse should take to assess the client's mobility and balance. Sitting on the edge of the bed for 2 min allows the nurse to observe the client's posture, strength, coordination, and ability to maintain equilibrium.
D) This is a more advanced mobility assessment and should come after basic assessments like placing feet on the floor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Standing requires more mobility and strength; it's not the first step in assessing mobility.
B) Placing feet on the floor assesses the client's ability to follow instructions and indicates readiness for further mobility assessments but is not the first step compared to sitting on the edge of the bed for 2 minutes.
C) This is the first action that the nurse should take to assess the client's mobility and balance. Sitting on the edge of the bed for 2 min allows the nurse to observe the client's posture, strength, coordination, and ability to maintain equilibrium.
D) This is a more advanced mobility assessment and should come after basic assessments like placing feet on the floor.
Correct Answer is D
Explanation
A) Age-related changes in bone density often involve decreased calcium deposition, not increased calcification.
B) Muscle mass tends to decrease with age, known as sarcopenia, rather than increase.
C) Balance typically declines with age due to changes in sensory input, muscle strength, and joint flexibility.
D) Joint stiffness commonly occurs as a result of age-related changes such as decreased synovial fluid production and cartilage degeneration.
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