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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Rotation: Rotation is a movement that involves turning a part of the body around its axis, which applies to shoulder movements.
B. Dorsiflexion: Dorsiflexion refers to the movement of the foot, not the shoulder, and is not applicable in this context.
C. Eversion: Eversion involves the movement of the foot and not the shoulder, so it does not apply here.
D. Extension: Extension refers to increasing the angle between body parts, such as straightening the arm or shoulder.
E. Adduction: Adduction involves moving a body part toward the midline, which is relevant to shoulder movements.
Correct Answer is B
Explanation
A. Gait belt with handles: A gait belt can provide support and stability during transfers, but it is generally used for walking rather than transferring directly from bed to chair.
B. Lateral-assist transfer board: A lateral-assist transfer board can help with moving the patient from bed to chair by sliding, making it appropriate for this transfer scenario.
C. Powered stand-assist aid: A powered stand-assist aid is typically used to help patients who need assistance standing and could be appropriate if the patient requires more support during the transfer.
D. Powered full-body lift: A powered full-body lift is generally used for patients who cannot bear weight at all and would not be necessary for a patient who can bear weight on one leg and use a walker.
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