The nurse is teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?

Ask the patient to try to stand up independently to assess the patient's strength first.

Remind the patient to look up to ensure good positioning when standing up.

Allow the patient to dangle at the edge of the bed before standing to assess for feelings of dizziness.

Assess the patient for any numbness or tingling in the extremities.

Answer and Explanation

The Correct Answer is A

A. Ask the patient to try to stand up independently to assess the patient's strength first. This action is inappropriate as it may put the patient at risk of falling or injury. The patient should be assisted rather than asked to stand independently.

B. Remind the patient to look up to ensure good positioning when standing up. This is a correct action. Looking up helps the patient maintain better posture and balance when standing.

C. Allow the patient to dangle at the edge of the bed before standing to assess for feelings of dizziness. This is appropriate as it helps to identify any dizziness or orthostatic hypotension before the patient attempts to stand.

D. Assess the patient for any numbness or tingling in the extremities. This is also appropriate as it helps to identify any neurological issues that could affect the patient's ability to stand and transfer safely.

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Correct Answer is B

Explanation

A. Acute pain: This diagnosis might be relevant if the patient has pain, but it does not address the main concern of mobility and risk related to recent falls.

B. Risk for injury: This is the most appropriate diagnosis as the patient’s inability to bear weight and recent falls increase their risk of further injury.

C. Activity Intolerance: While the patient may have activity intolerance, the more pressing concern related to their recent falls and inability to bear weight is the risk for injury.

D. Toileting self-care deficit: This diagnosis might be relevant if there were specific issues with toileting, but it is not the most appropriate for the general risk of injury due to recent falls.

A. Displacement B. Rationalization C. Dissociation D. Projection

Correct Answer is B

Explanation

A. Displacement: Displacement involves transferring feelings to a less threatening object or person, which is not applicable to the client’s statement.

B. Rationalization: Rationalization involves justifying behaviors or feelings with logical reasons. The client’s statement reflects an unrealistic view rather than justifying actions.

C. Dissociation: Dissociation involves a disconnection from thoughts or feelings, which is not reflected in the client's statement.

D. Projection: Projection involves attributing one’s own feelings or thoughts to others. The client is expressing their own feelings about the wheelchair rather than attributing them to others.

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The nurse is teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing the plan of care for a patient who is unable to bear weight on the right foot. The patient requires assistance to get out of bed and has recently fallen. Which of the following nursing diagnosis would be most appropriate for this patient?

Correct Answer is B

Explanation

The nurse is assisting a client, from the bed into a wheelchair, who had a right-side below the knee amputation one day ago. The client states, "I will not be able to do much because of this wheelchair." The client is demonstrating which of the following defense mechanisms?

Correct Answer is B

Explanation

The nurse is assessing the vital signs of a sleeping patient at 0400 a.m. and notes the patient is experiencing stage IV non-rapid eye movement (NREM) sleep. The nurse should expect which of the following findings?

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