A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment?

The client's ability to sit.

The condition of the client's skin.

The client's health literacy level.

The client's need for assistance with ADLS.

The client's daily calcium intake.

Answer and Explanation

Correct Answer : A,D

A. The client’s ability to sit: Assessing whether the client can sit independently provides important information about balance, posture, and muscle strength, all of which are central to mobility. This helps determine the level of support or equipment the client may need.

B. The condition of the client’s skin: Skin condition is important for overall assessment but is more closely related to skin integrity and pressure injury risk. While relevant to care, it does not directly evaluate mobility.

C. The client’s health literacy level: Health literacy affects the client’s ability to understand instructions and education, but it does not provide data on physical movement or mobility status.

D. The client’s need for assistance with ADLs: Assessing the client’s ability to perform activities of daily living, such as bathing, dressing, and walking, reflects functional mobility. This data is essential in planning interventions and support.

E. The client’s daily calcium intake: Calcium intake is related to long-term bone health but does not directly measure the client’s current mobility or physical ability. It would be assessed in nutritional evaluation rather than mobility assessment.

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Correct Answer is B

Explanation

A. B complex: The B vitamins are water-soluble and play roles in energy metabolism, nerve function, and red blood cell production. They are not directly linked to vision or night blindness.

B. A (retinol): Vitamin A is essential for the production of rhodopsin, a pigment in the retina that allows for vision in low-light conditions. Deficiency leads to night blindness and, if prolonged, can cause more severe eye damage such as xerophthalmia.

C. D: Vitamin D is important for calcium absorption and bone health. Deficiency results in rickets in children and osteomalacia in adults, but it does not cause difficulty with night vision.

D. K: Vitamin K plays a crucial role in blood clotting and bone health. Its deficiency leads to impaired coagulation and increased bleeding risk, not visual disturbances or night blindness.

A. Wear open-toed shoes. B. Apply lotion between the toes. C. Wash feet in hot water. D. Avoid walking barefoot.

Correct Answer is D

Explanation

A. Wear open-toed shoes: Open-toed shoes expose the feet to trauma, cuts, and infections, which are especially risky for clients with neuropathy due to reduced sensation and delayed healing. Closed, supportive footwear is safer.

B. Apply lotion between the toes: Moisturizer is recommended for dry skin, but it should not be applied between the toes. Moisture in this area promotes fungal growth and infection, which can worsen complications in diabetic clients.

C. Wash feet in hot water: Hot water increases the risk of burns because clients with neuropathy may not feel the temperature accurately. Feet should be washed in lukewarm water to prevent injury.

D. Avoid walking barefoot: Clients with diabetic neuropathy should always protect their feet because they are at high risk for unnoticed injuries and infections. Avoiding barefoot walking is a critical teaching point for foot care.

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A nurse is performing a mobility assessment on a client. Which of the following data should the nurse collect as part of this assessment?

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Naxlex Comprehensive Predictor Exams

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