The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

Bends from the waist to pick trash off the floor.

Leans forward to pull a pan from a high shelf.

Locks knees while preparing food on the counter.

Widens stance while working near the sink.

Brings a heavy can close to body before lifting.

Answer and Explanation

Correct Answer : D,E

A.   Bending from the waist to pick up trash can cause imbalance and strain; it is safer to bend at the knees.

B.   Leaning forward to pull a pan from a high shelf can lead to loss of balance; using a step stool is safer.
C.   Locking the knees can lead to loss of balance and is not a recommended posture.

D. Widening the stance provides a stable base and helps maintain balance while working.
E. Bringing a heavy can close to the body before lifting uses proper body mechanics, reducing the risk of strain and promoting balance.

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Correct Answer is D

Explanation

A. This requires prompt attention but is not immediately life-threatening.

B. This requires attention but does not pose an immediate threat to the client's condition.

C. An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D. Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9°C) B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg. D. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.

Correct Answer is A

Explanation

A. The client with viral meningitis and a slight increase in temperature can be managed by a PN, as this change in status is less acute and requires standard nursing care and monitoring.

B. The client with myxedema coma experiencing a significant drop in blood pressure requires more complex and immediate intervention by an RN due to the critical nature of the condition.
C. The client with a subdural hematoma and a significant change in blood pressure needs close monitoring and potential interventions by an RN, given the risk of increased intracranial pressure.
D. The client with diabetic ketoacidosis and a decreased Glasgow Coma Scale score is in a critical state requiring close monitoring and management by an RN.

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The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

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Naxlex Comprehensive Predictor Exams

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Correct Answer is D

Explanation

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

Correct Answer is A

Explanation

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