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. Minimal assist means that the client needs some verbal cues or light touch to perform an activity.
B. Moderate assist means that the client needs physical assistance from one person to perform an activity.
C. The client's ability to rise from a seated position using a cane for support indicates that they require no assistance from the nurse or another person to perform this activity. Therefore, the appropriate activity level assignment is "No assist."
D. Maximum assist means that the client needs physical assistance from two or more people to perform an activity.
Correct Answer is D
Explanation
A) Connect muscles to bones and aid in movement but are not fluid-filled capsules.
B) Provides cushioning between bones and aids in smooth movement but is not fluid- filled.
C) Connect bones to other bones and provide stability but are not fluid-filled capsules.
D) Synovial joints are surrounded by a fluid-filled capsule called the synovial membrane, which lubricates the joint and enables movement and flexibility.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today