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 C

Explanation

C. A clear liquid diet typically includes transparent or translucent liquids that are easy to digest and leave minimal residue in the gastrointestinal tract. Coffee, especially if it contains milk or creamer, is not considered a clear liquid and is not usually permitted on a clear liquid diet.

A. Reminding the client no milk or creamer can be added to the coffee may be appropriate for clients on other dietary restrictions but does not address the issue of coffee not being part of a clear liquid diet.

B. Determining which member of the nursing staff brought the cup of coffee to the client is not necessary unless there is a need to investigate a specific incident or identify potential lapses in care.

D. Consulting with the dietitian to learn if the client is allowed to drink coffee may be appropriate for clarifying dietary restrictions or allowances, but in the context of a clear liquid diet, coffee is typically not permitted regardless of the dietitian's input.

A. Weakened cough effort. B. Hypoactive bowel sounds. C. Urinary incontinence. D. Plus two ankle edema.

Correct Answer is C

Explanation

C. Urinary incontinence affects the moisture component of the Braden scale. Proper assessment and interventions are crucial to prevent skin breakdown.

A. A weakened cough effort is not directly related to pressure ulcer risk assessment, which is the purpose of the Braden Scale.

B. Bowel sounds are not included in the Braden Scale assessment criteria.

D. Ankle edema is not included as a factor in the Braden Scale assessment.

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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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Naxlex Comprehensive Predictor Exams

The nurse observes a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is C

Explanation

It is most important for the nurse to recalculate the Braden scale score for a client who has developed which problem?

Correct Answer is C

Explanation

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