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. 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.

A. Assess the patient for physiological indicators of pain. B. Observe the patient for behavior that is indicative of pain. C. Involve the patient in the pain assessment by asking more direct questions. D. Compare the patient's facial expression to a FACES pain scale.

Correct Answer is C

Explanation

A. Assess the patient for physiological indicators of pain. While assessing physiological indicators (such as increased heart rate, blood pressure, or sweating) can provide clues about pain, these signs are not always reliable and can be influenced by other factors. This option does not directly address the patient’s verbal and non-verbal communication about their pain.

B. Observe the patient for behavior that is indicative of pain. Observing the patient’s behavior can be helpful, but it is not sufficient on its own. The patient’s cultural background may influence how they express pain, and relying solely on observation might lead to underestimating their pain.

C. Involve the patient in the pain assessment by asking more direct questions. This is the best option because it respects the patient’s cultural background and encourages a more accurate and detailed assessment of their pain. By asking direct questions, the nurse can gain a better understanding of the patient’s pain experience and provide appropriate care.

D. Compare the patient's facial expression to a FACES pain scale. Using a FACES pain scale can be useful, especially for patients who have difficulty verbalizing their pain. However, this option does not involve the patient in a more detailed discussion about their pain, which is crucial given the cultural context and the patient’s reluctance to openly admit to pain.

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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?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

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