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

D. The most appropriate action for the nurse to take is to gather more information about the client's exercise schedule. This will help the nurse assess whether the client's exercise regimen may be contributing to or exacerbating the insomnia. Understanding the timing, intensity, and duration of the client's aerobic workouts can provide insights into potential factors affecting sleep patterns.

A. Advising the client that lifestyle changes often take several weeks to be effective is a valid point. However, it does not directly address the potential impact of exercise timing on sleep.

B. Determining the amount of weight the client has lost since increasing activity may provide useful information about the client's progress with weight loss but does not directly address the issue of difficulty falling asleep.

C. Encouraging the client to exercise every day to eliminate bedtime wakefulness is not necessarily appropriate, as excessive or late-night exercise may exacerbate rather than alleviate bedtime wakefulness in some individuals.

A. On dorsal surfaces. B. Over the heels. C. Around the ankles. D. Between the toes.

Correct Answer is D

Explanation

D. Thoroughly drying between the toes is essential for preventing moisture buildup, which can contribute to the development of fungal infections such as athlete's foot. In a client with diminished circulation in the lower extremities, ensuring proper drying between the toes becomes even more critical to reduce the risk of skin breakdown and infection.

A, B, C- drying the dorsum, heels and ankle regions is important to prevent maceration of skin but they are not the areas commonly affected by infection in cases of compromised circulation.

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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?

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A client tells the nurse about starting an aerobic workout program to lose weight and help with insomnia. The client states that it still takes over an hour to fall asleep at night. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry them. While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?

Correct Answer is D

Explanation

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