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 A
Explanation
Choice A rationale:
When caring for a client at the end of life who is unresponsive, it is essential to maintain a compassionate and supportive presence. Continuing to talk to the client as if they are awake is a respectful and therapeutic approach. Even though the client may not respond verbally, they may still be able to hear and sense the presence of their loved ones and the healthcare team. This communication can provide comfort and reassurance.
Choice B rationale:
Limiting the client's visitors to one at a time is a reasonable consideration, as it can help reduce potential overwhelm and maintain a calm environment. However, this choice should be based on the client's and family's preferences. Some clients and families may prefer to have multiple visitors present for support and companionship during this difficult time.
Choice C rationale:
Avoiding touching the client is not recommended when caring for an unresponsive client at the end of life. Physical touch, when gentle and respectful, can convey comfort and support. The nurse should be sensitive to the client's preferences and the family's wishes regarding physical contact.
Choice D rationale:
Whispering when talking in the client's room is not necessary. While it's important to maintain a quiet and peaceful environment, speaking in a normal tone is appropriate. The client may still be able to hear and may find comfort in the familiar voices of their loved ones and the healthcare team. .
Correct Answer is A
Explanation
Choice A rationale:
Role performance. Role performance is a self-concept stressor that occurs when individuals struggle to meet their responsibilities and expectations in various roles, such as work, family, or social roles. In this scenario, the client is feeling stressed due to the demands of work and caring for an ill family member, indicating a struggle with their roles and responsibilities.
Choice B rationale:
Body image. Body image relates to how individuals perceive and feel about their physical appearance. It is not the primary self-concept stressor described in this situation. While stressors related to body image can cause psychological distress, the client's stress is primarily linked to their roles and responsibilities.
Choice C rationale:
Self-esteem. Self-esteem refers to an individual's overall self-worth and self-evaluation. While it can contribute to stress in various situations, the client's stress in this case is more directly related to their role performance and responsibilities.
Choice D rationale:
Identity. Identity concerns are related to an individual's sense of self and how they define themselves in terms of their values, beliefs, and personal characteristics. While identity can be a source of stress in some cases, the client's reported stress is primarily due to their inability to manage their roles effectively.
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