A nurse is working with an older adult and educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears disengaged and states, “I’m just too old to learn.” What would be most appropriate for the nurse to do to motivate this client?

Tell the client how to move the walker as the client ambulates

Describe how the walker can improve the client’s quality of life

Explain how the walker supports the client’s lower extremities

Fully discuss the rationale for using the walker

Answer and Explanation

The Correct Answer is B

Choice A reason: Instructing on walker movement addresses the psychomotor domain, focusing on physical skills. This does not tackle the client’s emotional disengagement or belief of being “too old.” Without addressing motivation, technical instructions may be ineffective, as the client’s psychological barrier prevents engagement, reducing the likelihood of successful learning and adoption.

Choice B reason: Describing quality-of-life benefits targets the affective domain, addressing emotions and attitudes. By emphasizing enhanced independence, safety, and mobility, the nurse can counter the client’s defeatist mindset. This approach fosters motivation, making the client more receptive to learning walker use, as it connects the intervention to personal, meaningful outcomes.

Choice C reason: Explaining walker support for lower extremities focuses on the cognitive domain, providing technical knowledge. While informative, it does not address the client’s emotional disengagement. Without motivating the client by linking the walker to personal benefits, this approach may fail to overcome their resistance, as it lacks an emotional or motivational component.

Choice D reason: Discussing the rationale for walker use targets the cognitive domain, explaining its purpose. While this may enhance understanding, it does not address the client’s emotional barrier or lack of motivation. Without engaging the client’s feelings or highlighting personal benefits, the rationale alone is unlikely to inspire willingness to learn or use the walker.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Leg swelling (edema) is a symptom of heart failure due to fluid retention from poor cardiac output. However, it is less urgent than breathing difficulties, which indicate pulmonary edema, a life-threatening complication. Assessing breathing takes priority, as it directly affects oxygenation, a critical physiological need.

Choice B reason: Difficulty breathing (dyspnea) is a hallmark of heart failure, often due to pulmonary edema from fluid backup in the lungs. This compromises oxygenation, making it a life-threatening symptom requiring immediate assessment. The ABCD-E framework prioritizes breathing, making this the most critical question to evaluate heart failure severity.

Choice C reason: Chest pain may indicate angina or myocardial infarction, which can contribute to heart failure. However, it is less specific to heart failure than dyspnea, which directly signals pulmonary congestion. Breathing difficulties pose a more immediate threat, as they affect oxygenation, a priority in acute heart failure assessment.

Choice D reason: Heart palpitations may occur in heart failure due to arrhythmias but are less specific and urgent than dyspnea. Palpitations may indicate stress or other conditions, but breathing difficulties directly reflect pulmonary edema, a critical complication requiring immediate attention to ensure adequate oxygenation and prevent respiratory failure.

A. To obtain homeostasis B. To prevent infection C. To promote mobility D. To enhance nutrition

Correct Answer is A

Explanation

Choice A reason: Homeostasis is the body’s ability to maintain stable internal conditions, including fluid and electrolyte balance. Imbalances, like hypokalemia or hypernatremia, disrupt cellular function, potentially causing arrhythmias or neurological issues. Restoring homeostasis is the priority, as it addresses the root cause, ensuring proper organ function and preventing complications.

Choice B reason: Preventing infection is important but not the priority in fluid and electrolyte imbalances. Infections may occur secondary to other conditions, but the primary concern is correcting imbalances that affect cellular and organ function. Homeostasis must be achieved first to stabilize the client’s physiological state before addressing infection risks.

Choice C reason: Promoting mobility is relevant for overall health but not the priority in fluid and electrolyte imbalances. Imbalances can cause muscle weakness or arrhythmias, but restoring electrolyte levels takes precedence to ensure safe mobility. Without homeostasis, mobility efforts may be unsafe or ineffective due to physiological instability.

Choice D reason: Enhancing nutrition supports overall recovery but is secondary to correcting fluid and electrolyte imbalances. Nutritional deficiencies may contribute to imbalances, but the immediate goal is restoring homeostasis to prevent acute complications like cardiac or neurological dysfunction. Nutrition can be addressed once the client is stabilized.

View Question and Answer

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

A nurse is working with an older adult and educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears disengaged and states, “I’m just too old to learn.” What would be most appropriate for the nurse to do to motivate this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client and asks which of the following questions to evaluate potential heart failure symptoms?

Correct Answer is B

Explanation

A nurse is caring for a client who has a fluid and electrolyte imbalance. The nurse knows that the priority goal of taking care of this client is?

Correct Answer is A

Explanation

A client states to the nurse, “I understand that I need a mastectomy, but I am worried about the pain and appearance afterwards.” When responding to the client, the nurse will need to address which domain?

The client is admitted to the nurse’s unit with a diagnosis of heart failure. His heart is not pumping effectively, resulting in edema and coarse crackles in his lungs. The term for this condition is?

As the nurse assesses a client’s blood pressure, the patient’s wrist severely flexes inward. The nurse questions the client’s response because this finding may indicate what condition?

indicate the nurse is addressing the affective domain of learning?

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

A nurse is receiving report on a group of clients. Using the ABCD-E priority framework, which of the following clients should the nurse see first?

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which oxygen delivery method is most appropriate for this client?

A 73-year-old hospitalized client demonstrates the following symptoms: dry mucous membranes, decreased urine output, confusion, a serum sodium of 158 mEq/L, a potassium of 4.8 mEq/L. The nurse recognizes that these symptoms are indicative of?