A nurse is conducting the Weber's test on a client. Which of the following is an appropriate action for the nurse to take?

D. This statement shows a good understanding of measures to reduce the adverse effects of immobility. Regularly performing ankle and knee exercises helps promote circulation, prevent muscle atrophy, and reduce the risk of DVT and joint stiffness. Hourly exercises are an excellent practice to mitigate the negative effects of immobility.
A. This statement indicates a misunderstanding. Holding the breath while changing positions can lead to a Valsalva maneuver, which can cause a sudden drop in blood pressure and increase the risk of dizziness or fainting, especially in immobile clients. Instead, clients should be encouraged to breathe normally and rise slowly to avoid orthostatic hypotension.
B. This frequency of position changes is inadequate for preventing pressure ulcers. It is generally recommended to change positions at least every 2 hours to prevent pressure on any one area of the body for too long. Therefore, this statement indicates a partial understanding but needs adjustment to more frequent position changes.
C. Antiembolic stockings (TED hose) are designed to promote venous return and reduce the risk of DVT. They are typically worn continuously, except during hygiene routines or as directed by a healthcare

provider. Removing them while in bed could increase the risk of thrombus formation. This statement indicates a misunderstanding of their purpose and usage.

D. Demonstrates the nurse's commitment to advocating for the client's wishes and ensuring that their preferences are communicated to the healthcare provider. This response acknowledges the client's desire for ongoing treatment while also facilitating further discussion with the healthcare team about the available options and potential treatment modalities.
A. This may be premature and could be perceived as dismissive of the client's wishes. While hospice care may be appropriate for some clients with terminal illnesses, it should be introduced as an option after thorough discussion and consideration of the client's preferences and goals of care.
B. This may be blunt and insensitive, potentially causing distress or anxiety for the client. It is important to provide information about prognosis in a sensitive and empathetic manner, taking into account the client's emotional state and readiness to discuss such matters.
C. This may overlook the client's desire for continued treatment and may not fully address their concerns or needs. While encouraging the client to focus on quality of life and personal fulfillment is important, it should be done in conjunction with discussions about treatment options and goals of care.