Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

Balance and posture.

Risk for disuse syndrome.

Pressure sore risk.

Upper body muscle strength.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Balance and posture: Although relevant for general mobility, a trapeze bar is primarily used while in bed, where balance and posture are less critical than the strength to use the device effectively.

B. Risk for disuse syndrome: This risk supports the need for mobility aids like a trapeze, but it does not determine whether the client can use the device safely and independently.

C. Pressure sore risk: This is important for overall care planning, but not the most relevant assessment for determining safe and effective trapeze use.

D. Upper body muscle strength: Adequate arm and shoulder strength are essential for the client to grasp and lift themselves using the trapeze bar. Without this, using the bar could lead to falls or injuries.

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Correct Answer is B

Explanation

Rationale:
A. Full volume of pedal pulses: Pedal pulses reflect peripheral arterial circulation, not neuropathic pain. Pregabalin does not affect vascular flow, so this finding is unrelated to the medication’s intended effect.

B. Reduced level of pain: Pregabalin is an anticonvulsant used to treat neuropathic pain by modulating nerve signals. A reduction in reported pain confirms that the medication is helping manage the client’s diabetic nerve pain.

C. Granulating tissue in foot ulcer: Wound healing is influenced by infection control, circulation, and blood glucose management—not directly by pregabalin. While important, this finding does not measure the drug’s effectiveness for neuropathy.

D. Improved visual acuity: Visual changes are not treated with pregabalin and may be associated with diabetic retinopathy. Pregabalin does not improve vision and is not indicated for ocular complications of diabetes.

A. A family member expresses concern about their relative "picking" at the nasal gastric tube (NG) tube. B. A client is walking the halls at night rubbing his hands together. C. A 16-year-old boy swung his fist at the nurse. D. A disoriented client removed the mesh wrapped intravenous (IV) line for the second time.

Correct Answer is D

Explanation

Rationale:

A. A family member expresses concern about their relative "picking" at the nasogastric (NG) tube: Family concern should be acknowledged, but restraint use must be based on clinical necessity. The nurse can first implement non-restrictive interventions before considering restraints.

B. A client is walking the halls at night rubbing his hands together: This behavior does not indicate harm to self or others or interference with medical devices. There is no justification for restraint, and doing so could violate patient rights and ethical standards.

C. A 16-year-old boy swung his fist at the nurse: This may call for emergency behavioral restraints rather than mitten restraints. If the behavior poses a threat of violence, other forms of crisis intervention or behavioral management should be pursued first.

D. A disoriented client removed the mesh-wrapped intravenous (IV) line for the second time: Mitten restraints may be considered when a client repeatedly removes critical lines or tubes, especially when cognitively impaired. This situation meets the clinical indication for discussing their use with the provider to prevent treatment disruption while ensuring safety.

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Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

Correct Answer is B

Explanation

Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

Correct Answer is D

Explanation

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