A nurse is preparing to reposition a client.
Which of the following actions should the nurse take first?
Tighten their abdominal muscles.
Raise the height of the client's bed.
Pivot their feet in the direction of the move.
Place their feet in line with their shoulders.
The Correct Answer is D
Choice A rationale:
Tightening abdominal muscles is not the first action the nurse should take when repositioning a client. Repositioning a client requires proper body mechanics and coordination. Tightening abdominal muscles may not be as effective or safe as other actions in ensuring the client's safety during repositioning.
Choice B rationale:
Raising the height of the client's bed is not the first action the nurse should take when repositioning a client. Adjusting the bed height is a secondary consideration and can be done after ensuring proper body mechanics and patient safety during the repositioning process.
Choice C rationale:
Pivoting the feet in the direction of the move is a crucial step when repositioning a client. This action allows the nurse to maintain balance and control during the transfer. It also reduces the risk of injury to the nurse and the client. However, it is not the first action to be taken.
Choice D rationale:
Placing the feet in line with the shoulders is the first action the nurse should take when repositioning a client. This wide base of support provides stability and balance. It allows the nurse to maintain control during the repositioning process, reducing the risk of injury to both the nurse and the client. After achieving this stable stance, pivoting the feet in the direction of the move is the next step to facilitate the repositioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Full thickness skin loss with visible bone. This choice does not align with the description of a stage 2 pressure injury. Stage 2 pressure injuries are characterized by partial-thickness skin loss, but they do not involve visible bone. This description corresponds to a more severe stage of pressure injury.
Choice B rationale:
Intact skin with localized erythema. This choice describes a normal skin condition with localized redness (erythema) but does not indicate the presence of a pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss, which means there is a break in the skin integrity.
Choice C rationale:
Full thickness skin loss with visible adipose tissue. This description is more in line with a stage 3 pressure injury, not a stage 2 injury. In stage 3, there is full-thickness skin loss, and adipose tissue may become visible in the wound bed. However, in stage 2, the skin loss is partial-thickness, and the wound bed typically contains red tissue.
Choice D rationale:
Partial-thickness skin loss with red tissue in the wound bed. This choice is the correct description of a stage 2 pressure injury. Stage 2 pressure injuries involve partial-thickness skin loss with the presence of red or pink tissue in the wound bed. It signifies damage to the epidermis and possibly the dermis. .
Correct Answer is C
Explanation
Choice A rationale;
Inability to form healthy relationships: This is more commonly associated with fixation at the phallic stage.
Choice B rationale:
Feelings of shame are associated with Freud's psychosexual stages, particularly during the anal stage. Fixation at the oral stage is more likely to result in issues related to dependency and oral fixation, which may manifest as habits like nail-biting or smoking, rather than feelings of shame.
Choice C rationale:
According to Freud's psychosexual theory, fixation at the oral stage can lead to oral personality traits. These traits are often associated with oral activities like eating, drinking, smoking, and talking. Overeating is a common behavior linked to oral fixation, as it represents a seeking of oral gratification.
Choice D rationale:
Bedwetting is not typically associated with fixation at the oral stage of development. Bedwetting is more commonly linked to issues at the anal stage. In the oral stage, the fixation is primarily related to dependency and oral behaviors. .
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