The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

Initiate a fall risk protocol for the client.

Teach the client to shorten the stride to prevent falls.

Determine the client's activity tolerance.

Record the client's ability to perform ADLS safely.

Answer and Explanation

The Correct Answer is C

A. Initiate a fall risk protocol for the client:

Initiating a fall risk protocol may be premature based solely on observations of an upright posture and a smooth, steady gait. While falls are a significant concern in older adults, these observations suggest that the client currently exhibits good balance and mobility, which may not warrant immediate initiation of a fall risk protocol. Fall risk assessments typically involve a comprehensive evaluation of multiple factors beyond posture and gait, such as medical history, medications, cognitive status, and environmental factors.

B. Teach the client to shorten the stride to prevent falls:

Teaching the client to shorten their stride to prevent falls may not be necessary based on the observed smooth and steady gait. Shortening the stride is often recommended for individuals who exhibit signs of imbalance or instability during walking. However, in this scenario, the client demonstrates a smooth and steady gait, suggesting that their current gait pattern is effective and does not pose an immediate risk of falling.

C. Determine the client's activity tolerance:

Assessing the client's activity tolerance is an appropriate next step in the nursing process. While the observed upright posture and smooth, steady gait are positive indicators of mobility, understanding the client's overall activity tolerance provides valuable insight into their functional capacity and ability to perform activities of daily living safely. This assessment helps tailor care interventions to meet the client's individual needs and promotes optimal independence and quality of life.

D. Record the client's ability to perform ADLs safely:

Documenting the client's ability to perform activities of daily living (ADLs) safely is an essential component of nursing assessment and documentation. However, it may not be the most immediate action to take following the observation of an upright posture and smooth, steady gait. While documenting findings is important for maintaining accurate records and facilitating communication among healthcare team members, further assessment of the client's activity tolerance would provide additional context for documenting their functional status accurately.

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Correct Answer is C

Explanation

A. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care:

This option might be tempting but is not appropriate because the UAP should be properly equipped with the correct protective gear before any contact with the client. Bacterial meningitis requires droplet precautions, and a standard face mask is sufficient for this type of precaution, not a particulate filter mask.

B. Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client:

This action is unnecessary because bacterial meningitis requires droplet precautions, which only necessitate a standard surgical mask, not a particulate filter mask like an N95, which is used for airborne precautions. This option indicates a misunderstanding of the type of precautions needed for bacterial meningitis.

C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client:

This is the correct course of action. Bacterial meningitis requires droplet precautions, which only require a standard face mask. The UAP can safely provide care using a standard mask.

D. Before changing assignments, determine which staff members have fitted particulate filter masks:

While it is prudent to know which staff members are fitted for particulate filter masks, this is not necessary for caring for a client with bacterial meningitis under droplet precautions. The focus should be on ensuring the UAP understands that a standard mask is sufficient.

A. Obtaining clarification from a client's healthcare power-of-attorney. B. Completing discharge teaching to a client and family members. C. Reporting a change in a client's condition to the healthcare provider. D. Offering therapeutic support and comfort to a grieving family.

Correct Answer is C

Explanation

A. Obtaining clarification from a client's healthcare power-of-attorney:

While clear communication is important in this scenario, SBAR may not be necessary as the nurse is seeking information rather than providing a detailed report or recommendation.

B. Completing discharge teaching to a client and family members:

SBAR may not be the most suitable format for discharge teaching, as it is primarily used for communication between healthcare providers regarding a patient's condition and care plan. Discharge teaching typically involves providing comprehensive instructions and information in a manner tailored to the needs of the client and family members.

C. Reporting a change in a client's condition to the healthcare provider:

This is the most appropriate scenario for using the SBAR format. When communicating a change in a client's condition to the healthcare provider, the SBAR framework allows the nurse to provide a concise summary of the situation, relevant background information, assessment findings, and recommendations for further action.

D. Offering therapeutic support and comfort to a grieving family:

SBAR communication is not suitable for offering therapeutic support and comfort to a grieving family. This interaction requires empathy, active listening, and emotional support rather than a structured communication format like SBAR.

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The nurse assesses an older adult client's ability to perform activities of daily living (ADLs). When observing the client ambulate, the nurse notes that the client's posture is upright, and the gait is smooth and steady. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse plans to use the Situation, Background, Assessment, and Recommendation (SBAR) format of communication during which interaction?

Correct Answer is C

Explanation

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