The nurse is assisting to lift a client from a wheelchair after surgery. To ensure safe mobility, which action should the nurse take?

Bend at the knees to maintain a low center of gravity.

Ask the client to place hands on the nurse's shoulders.

Stand with feet 3 inches (7.6 cm) apart for balance.

Position self at the back of wheelchair with wheels locked.

Answer and Explanation

The Correct Answer is A

A. Bend at the knees to maintain a low center of gravity: Bending at the knees allows the nurse to use the strong muscles of the legs instead of the back, promoting proper body mechanics and reducing the risk of injury during lifting.

B. Ask the client to place hands on the nurse's shoulders: This is unsafe, as it may cause the client to pull the nurse off balance. Clients should be instructed to push off stable surfaces, such as the armrests of the wheelchair.

C. Stand with feet 3 inches (7.6 cm) apart for balance: A 3-inch stance does not provide adequate support. Feet should be about shoulder-width apart (usually 12–18 inches) to maintain a stable base during lifting or transferring.

D. Position self at the back of wheelchair with wheels locked: While locking the wheels is correct, standing behind the wheelchair does not assist the client in rising. The nurse should be in front or to the side to offer support during the transfer.

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Correct Answer is D

Explanation

A. Review the pain medications prescribed: Reviewing available medications is useful for planning, but it should follow a more direct exploration of the client's current discomfort and verbal input.

B. Administer PRN oral pain medication: Administering medication without the client reporting pain or confirming the need can be inappropriate, especially if the client denies discomfort. Further assessment is needed first.

C. Monitor the client's nonverbal behavior: Continued observation is important but passive. The nurse should actively seek clarification to determine if intervention is needed.

D. Ask the client what is causing the grimacing: This approach respects the client's autonomy and provides an opportunity to explore the cause of the discomfort. It helps clarify if the grimacing is due to pain or another issue, guiding appropriate next steps.

Correct Answer is []

Explanation

Potential Condition: Anticipatory Grief

Anticipatory grief occurs before a significant loss, such as a loved one’s death, when the loss is expected. The family in this case is emotional, shocked, and showing signs of distress in response to the impending loss, indicating anticipatory grief rather than complicated or ambiguous grief.

Actions to Take:

Provide information on grief support groups: Giving the family access to community and professional support prepares them to cope during and after the loss.

Encourage and allow the family to express their feelings: Expressing emotions like sadness, anger, or disbelief is part of the grieving process. Validating these emotions helps families process anticipatory grief in a healthy way.

Parameters to Monitor:

Monitor for signs of masked grief: Some family members may suppress emotions, redirect their distress, or act in denial, which could hinder healthy coping and grieving.

Monitor for intense pain responses: These responses can indicate overwhelming or dysfunctional grief that may need additional psychological support or counseling.

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The nurse is assisting to lift a client from a wheelchair after surgery. To ensure safe mobility, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

Correct Answer is []

Explanation

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