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 C
Explanation
A. Urinary output: Monitoring urinary output is important for clients on chemotherapy due to renal toxicity risk, but it is unrelated to the localized effects of stomatitis. The priority in stomatitis is maintaining oral intake and preventing nutritional compromise.
B. Frequency of bowel movements: Bowel patterns may be affected by chemotherapy or medication use, yet they do not directly relate to oral mucosal inflammation. Stomatitis primarily interferes with eating and drinking rather than bowel elimination.
C. Ability to swallow: Assessing the client’s ability to swallow is most important because stomatitis causes painful ulcerations and inflammation in the mouth, which can impair eating, drinking, and medication administration. Difficulty swallowing increases the risk of malnutrition, dehydration, and weight loss.
D. Blood pressure while standing: Orthostatic blood pressure measurement is relevant for assessing fluid balance or cardiovascular stability but has no direct connection to stomatitis. The priority is evaluating how oral pain and lesions affect intake and swallowing safety.
Correct Answer is C
Explanation
A. Take her temperature and assess for additional signs of infection: While monitoring for infection is important postpartum, immediate uncontrollable shaking and feeling cold in a healthy client is usually a normal physiologic response rather than a sign of infection.
B. Elevate her legs in a shock position and apply external heat: Placing the client in a shock position is unnecessary unless there are signs of hypotension or poor perfusion. Uncontrolled shaking and feeling cold alone do not indicate shock.
C. Apply light, warmed blankets and assure her that this is normal following delivery: Postpartum chills are common and result from rapid hormonal and fluid shifts after delivery. Applying warmed blankets and providing reassurance helps the client feel more comfortable and addresses the normal physiologic response.
D. Encourage the client to turn to her left side and administer oxygen by face mask: Turning to the left side and giving oxygen is indicated for compromised circulation or respiratory distress. In a stable postpartum client experiencing normal chills, these interventions are unnecessary.
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