The nurse will be assisting the client to walk. What should the nurse do first?
Assist the client to a sitting position at the side of the bed
Determine the client's strength, coordination, and activity tolerance
Help the client into a standing position
Ask another nurse for assistance
The Correct Answer is B
B. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.
A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.
C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.
D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. A comprehensive approach ensures that all aspects of patient care, safety, and organizational processes are thoroughly reviewed and addressed according to TJC standards. This includes comprehensive assessments of patient needs, care plans, and quality improvement initiatives.
A. This term typically refers to the process of capturing images or videos at intervals over time. In the context of healthcare and TJC requirements, "time-lapsed" is not a standard term used by TJC.
B An emergency situation refers to a sudden and often critical medical situation requiring immediate attention and intervention. While TJC does have standards related to emergency preparedness and response in healthcare facilities, "emergency" is not specifically a type of TJC requirement in the context provided.
D. A focused approach refers to concentrating on specific areas or issues within healthcare organizations to address particular concerns or improvements. However, this is not specific about TJC.
Correct Answer is C
Explanation
C. Delirium is often reversible once the underlying cause is identified and treated (e.g., correcting electrolyte imbalances, managing infections, discontinuing medications contributing to delirium). With appropriate intervention, the mental status can improve, and the individual can return to their baseline cognitive function.
A. Dementia, on the other hand, is a chronic, progressive syndrome that primarily affects memory, thinking, behavior, and the ability to perform everyday activities. It does not typically cause acute changes in consciousness.
B. Memory impairment is a hallmark feature of dementia, especially in the early stages. In contrast, delirium primarily affects attention, awareness, and cognition acutely, with memory impairment being variable and not a defining feature.
D. Delirium develops rapidly, often over hours to days, in response to an acute medical condition, medication change, or other factors. It is characterized by a fluctuating course and can resolve once the underlying cause is managed.
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