The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which 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.

Widens stance while working near the sink.

Locks knees while preparing food on the counter.

Brings a heavy can close to body before lifting.

Leans forward to pull a pan from a high shelf

Answer and Explanation

Correct Answer : B,D

A)   Incorrect- This behavior is not safe for maintaining balance. Bending from the waist can increase the risk of falling. Clients should bend at the knees and use proper body mechanics to pick up objects from the floor.
B)   Correct- Widening the stance provides a broader base of support, which can help improve balance and stability while working near the sink. This is a safe behavior to maintain balance.
C)   Incorrect- Locking the knees while standing can lead to instability and decreased balance. It is recommended to keep the knees slightly flexed to maintain better balance.
D)   Correct- Bringing a heavy object close to the body before lifting minimizes strain on the back and helps maintain balance. This is a safe behavior when lifting objects.
E)   Incorrect- Leaning forward to pull an object from a high shelf can disrupt the center of balance and increase the risk of falling. It's important to use a step stool or ask for assistance when reaching for items on high shelves.

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Correct Answer is A

Explanation

The information that the nurse should obtain from the client first is: Reason for taking the aspirin.

It is important to first understand why the client was taking aspirin in order to determine the potential implications of switching to ibuprofen. Aspirin and ibuprofen are both nonsteroidal anti-inflammatory drugs (NSAIDs), but they have different indications and effects. Aspirin is commonly used for its antiplatelet properties to reduce the risk of heart attacks and strokes, while ibuprofen is primarily used for its analgesic and anti-inflammatory properties.

By understanding the reason for taking aspirin, the nurse can assess if the client was using it for its antiplatelet effects, which is important information to consider for the client's overall health and well-being.

Once the reason for taking aspirin is determined, the nurse can proceed to inquire about the other relevant information, such as the dosage of ibuprofen taken, presence of gastric pain, and amount of pain control. These details will help in assessing the client's current medication regimen, potential side effects or complications, and overall pain management.

A. Anxiety as evidenced by abdominal complaints secondary to depression. B. Imbalanced nutrition as evidenced by 25 pound (11 kg) weight loss in four months. C. Chronic low self-esteem as evidenced by feelings of worthlessness. D. Risk for self-directed violence as evidenced by feelings of hopelessness.

Correct Answer is D

Explanation

The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.

Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.

The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.

While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.

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

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity?

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?

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