An older postoperative client has the nursing problem, "Impaired mobility related to fear of falling." Which desired outcome best directs the practical nurse's (PN) actions for this client?
The client will use self-affirmation statements to decrease fear.
The client will ambulate with assistance for q4 hours.
The physical therapist will instruct the client in the use of a walker.
The PN will place a gait belt on the client prior to ambulation.
The Correct Answer is B
While all of the options address the issue of impaired mobility related to fear of falling, the desired outcome of ambulating with assistance q4 hours is the most specific and measurable goal. This outcome focuses on promoting mobility and addressing the client's fear of falling by providing the necessary assistance during ambulation. It ensures that the client is engaging in regular activity and working towards regaining mobility.
The other options address different aspects of the nursing problem:
A. "The client will use self-affirmation statements to decrease fear" is a potential intervention that can be used to address the client's fear of falling, but it does not directly address the issue of impaired mobility.
C. "The physical therapist will instruct the client in the use of a walker" is an intervention that can be helpful in improving mobility, but it does not specify the frequency or timing of ambulation.
D. "The PN will place a gait belt on the client prior to ambulation" is a specific intervention that ensures the safety of the client during ambulation, but it does not address the frequency or timing of ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
- Minimize the number of refined grains in the diet: Refined grains, such as white bread, white rice, and pasta, have had their bran and germ removed, resulting in a loss of fiber and nutrients. Including more whole grains in the diet, such as whole wheat bread, brown rice, and whole grain pasta, can help maintain stable blood sugar levels and reduce the risk of type 2 diabetes.
- Eliminate sugary beverages and juices from the diet: Sugary beverages, including soda, fruit juices, and sweetened teas, can contribute to weight gain and an increased risk of type 2 diabetes. Encouraging the client to choose water, unsweetened tea, or other sugar-free beverages can help reduce the intake of added sugars.
- Increase the amount of dietary fiber: Fiber-rich foods, such as fruits, vegetables, whole grains, legumes, and nuts, can help regulate blood sugar levels and improve insulin sensitivity. Encouraging the client to include these foods in their diet can be beneficial in reducing the risk of type 2 diabetes.
Incorrect:
D- Double the usual amount of protein in the diet: While protein is an essential nutrient, doubling the usual amount of protein in the diet may not be necessary or appropriate for everyone. It is important to follow individualized dietary recommendations and consult with a healthcare provider or registered dietitian for specific protein needs.
E- Only select food items with no fat: It is not necessary or advisable to eliminate all fat from the diet. Healthy fats, such as those found in avocados, nuts, seeds, and olive oil, are important for overall health. Choosing foods with healthier fats and moderating intake of saturated and trans fats is a more balanced approach to nutrition.
F- Take a cinnamon supplement: While cinnamon has been studied for its potential effects on blood sugar control, it is not a proven or recommended treatment for reducing the risk of type 2 diabetes. It's important to focus on overall dietary patterns and lifestyle factors rather than relying solely on supplements
Correct Answer is A
Explanation
Taking a rectal temperature requires a higher level of skill and carries a higher risk of injury compared to other methods, especially when dealing with a 2-year-old child with leukemia. Given the client's condition, it is important to minimize any potential harm or discomfort. Taking a tympanic temperature is a safer alternative that provides an accurate reading without the risk of injury.
B. Reminding the UAP to lubricate the thermometer before insertion is not appropriate because the PN should not encourage or support the UAP in performing a rectal temperature on a high-risk client. The focus should be on using a safer and less invasive method.
C. Instructing the UAP to report the results to the PN immediately is not necessary in this situation because the PN has already determined that taking a rectal temperature is not appropriate.
Instead, the PN should guide the UAP toward using the tympanic method.
D. Observing the UAP to ensure the thermometer is inserted correctly is not appropriate in this case because the PN has already determined that taking a rectal temperature is not the recommended course of action. It is more appropriate to redirect the UAP to use an alternative method.
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