When assisting a client from the bed into a wheelchair, the nurse assesses the client on standing and notices the client is weak and unsteady. What would be the recommended nursing intervention in this situation?
Return the client to the bed.
Use the call bell to summon the assistance of another nurse.
Place the client into the wheelchair.
Allow the client to keep standing for several minutes until balance returns.
The Correct Answer is A
A. Returning the client to the bed is the safest action when the client appears weak and unsteady upon standing. This helps prevent a potential fall or injury. Once the client is safely back in bed, the nurse can reassess and consider other options for mobility support.
B. Using the call bell may take time and does not ensure the client’s immediate safety, which is the priority in this moment.
C. Placing the client into the wheelchair while they are unsteady poses a high risk for falls or injury.
D. Allowing the client to continue standing may worsen the situation if they are already weak, increasing the risk of collapse or injury.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While pain can motivate protective behaviors, it does not directly increase personal strength.
B. Acute pain is a subjective experience but serves an important biological purpose.
C. Acute pain is protective because it warns an individual of tissue damage or disease, prompting actions to avoid further harm and seek treatment.
D. Pain is subjective, not objective, and while it can aid diagnosis, its primary role is protective rather than diagnostic.
Correct Answer is C
Explanation
A. Offering iced tea before bed is not appropriate because tea contains caffeine, which can further disrupt sleep.
B. Sleeping without socks has no relevance to sleep disruption related to nocturia (frequent urination at night).
C. Having the client take a diuretic (furosemide) in the morning is the most appropriate intervention. Diuretics increase urine output, and taking them later in the day can lead to nocturia, which disrupts sleep and may contribute to confusion or disorientation in older adults.
D. Encouraging frequent naps during the day can interfere with the client’s nighttime sleep pattern, potentially worsening insomnia or nighttime disorientation.
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