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

Teach the client to shorten the stride to prevent falls.

Record the client's ability to perform ADLs safely.

Initiate a fall risk protocol for the client.

Determine the client's activity tolerance.

Answer and Explanation

The Correct Answer is B

B. Observing the client's upright posture and smooth, steady gait suggests that she is able to ambulate safely without significant risk of falls.

A. This action may be appropriate if the nurse had observed an unsteady or shuffling gait that could increase the risk of falls. However, in this scenario, the nurse has noted that the client's gait is smooth and steady, indicating good balance and stability.

C. The client's upright posture and smooth, steady gait suggest that she has good mobility and balance, which are not indicative of an increased risk of falls.

D. The client's ability to ambulate with an upright posture and smooth, steady gait indicates that she is tolerating activity well. However, the primary focus at this point should be on documenting her functional abilities and assessing her level of independence in performing ADLs safely.

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Correct Answer is D

Explanation

A. Erythema (redness) and serosanguineous exudate (clear to blood-tinged fluid) are typical findings in the early stages of wound healing, especially within the first few days post-surgery. However, one week post-surgery, these signs should begin to decrease as the wound progresses through the inflammatory phase of healing.

B. Eschar (dry, black, or brown necrotic tissue) and slough (yellow or white soft tissue) are indicative of non-viable tissue and delayed wound healing.

C. Beefy red granulation tissue is a positive sign of healing. It indicates new tissue formation, which is essential for the healing process. Granulation tissue is typically moist, and its presence suggests that the wound is progressing well towards healing.

D.This indicates that the edges of the incision are properly closed and healing as expected.

A. Provide comfort measures such as topical warm application and tactile massage. B. Implement a 24-hour schedule of routine administration of prescribed analgesic. C. Assist the client to ambulate as much as possible during waking hours. D. Encourage increased fluid intake and measure urinary output every 8 hours. E. Determine client's subjective-measure of pain using a numerical pain scale.

Correct Answer is ["A","B","E"]

Explanation

A. Provide comfort measures such as topical warm application and tactile massage. Comfort measures can help alleviate chronic pain symptoms and provide relief to the client.

B. Implement a 24-hour schedule of routine administration of prescribed analgesic. Consistent administration of prescribed analgesics helps maintain pain control and manage chronic pain effectively.

E. Determine the client's subjective measure of pain using a numerical pain scale. Assessing the client's pain using a numerical pain scale allows for quantification of pain intensity, which helps guide pain management interventions and evaluate effectiveness.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client one-week postsurgery. Which finding should the nurse expect to see if the surgical incision is healing properly?

Correct Answer is D

Explanation

The nurse is reviewing the admission assessment of a client with chronic pain, which intervention(s) should the nurse include in the client's plan of care? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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