An older postoperative client has the nursing diagnosis, "Impaired mobility related to fear of falling" Which desired outcome best directs the practical nurse's (PN) actions for this client?
The PN will place a gait belt on the client prior to ambulation.
The client will use self-affirmation statements to decrease fear.
The physical therapist will instruct the client in the use of a walker.
The client will ambulate with assistance q4 hours
The Correct Answer is D
A. The PN will place a gait belt on the client prior to ambulation: Using a gait belt is a nursing intervention that enhances safety during ambulation, but it is not an outcome statement. Desired outcomes should describe the client’s behavior or achievement rather than the nurse’s actions.
B. The client will use self-affirmation statements to decrease fear: Positive self-talk may help reduce anxiety, but it does not address the measurable improvement in physical mobility. The goal should reflect functional progress in ambulation, which indicates recovery and confidence.
C. The physical therapist will instruct the client in the use of a walker: This describes an interdisciplinary intervention rather than a client-centered outcome. While physical therapy support is important, the desired outcome should focus on what the client is expected to accomplish.
D. The client will ambulate with assistance q4 hours: This outcome is specific, measurable, and directly related to the diagnosis of impaired mobility. It demonstrates progress toward overcoming the fear of falling through supported activity and aligns with nursing goals to restore safe mobility.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Feed the infant when he cries: Crying increases oxygen demand and energy expenditure, which can be risky for an infant with heart failure. Feeding during distress may exacerbate fatigue and respiratory compromise.
B. Allow infant to rest before feeding: Allowing the infant to rest conserves energy and reduces cardiac workload. Adequate rest before feeding helps the infant tolerate oral intake without becoming fatigued, supporting better nutritional intake and growth.
C. Weigh before and after feeding: While weighing can help assess intake, it is not a primary intervention for managing feeding in an infant with heart failure. The focus should first be on energy conservation and safe feeding practices.
D. Insert a nasogastric feeding tube: NG tube feeding is reserved for infants unable to take sufficient oral intake safely. If the infant can feed orally with appropriate rest, NG feeding is unnecessary and more invasive.
Correct Answer is B
Explanation
A. "Do you have someone who can help you cope with this?": Exploring support systems is important later, but the initial response should focus on acknowledging the mother’s emotions and providing empathy before moving to problem-solving.
B. "This must appear devastating to you at this moment.": This response shows empathy and emotional validation, allowing the mother to express her feelings openly. It builds rapport and demonstrates understanding, which is the most appropriate first step in offering emotional support.
C. "You can best help your child by remaining calm and positive.": Although encouraging calmness is helpful, this response minimizes the mother’s distress and may make her feel guilty for her emotional reaction, which is inappropriate at this time.
D. "What was happening right before your child was injured?": Asking about the event shifts focus away from the mother’s emotional needs and could intensify her guilt or distress, rather than providing immediate support and comfort.
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