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Measure the blood pressure in both arms: Measuring blood pressure in both arms is typically done to assess for vascular abnormalities such as subclavian artery stenosis or aortic pathology. Forearm weakness related to crutch use is more likely musculoskeletal or related to improper assistive device technique rather than a vascular cause.

Encourage additional rest periods: While rest may temporarily relieve muscle fatigue, it does not address the underlying cause of the forearm weakness. If the weakness is due to improper crutch positioning or incorrect weight bearing, continuing the same technique—even with rest—could lead to worsening strain or complications such as nerve compression injuries.

Demonstrate arm strengthening exercises: Strengthening exercises can improve upper extremity endurance for clients using assistive devices, but initiating them without first evaluating the client’s current crutch technique may be inappropriate. Weakness in this context is more likely due to incorrect biomechanics rather than inadequate strength.

Support joints in an extended position while resting: During an acute gout flare, inflamed joints are extremely painful and sensitive to movement or pressure. Forcing the joint into an extended position can increase discomfort and worsen inflammation. The affected joint is usually positioned for comfort, often slightly flexed and elevated, rather than immobilized in extension.

Eat high protein foods to achieve ideal body weight: High-protein foods, especially those rich in purines such as red meat and organ meats, can increase uric acid production and precipitate gout attacks. Dietary management for gout focuses on limiting purine-rich foods rather than increasing protein intake.

Limit use of mobility equipment to avoid muscle atrophy: During acute gout inflammation, assistive devices such as canes or crutches may actually help reduce weight bearing on the affected joint and decrease pain. Avoiding mobility aids could increase stress on inflamed joints and worsen symptoms. Muscle atrophy is unlikely with temporary use of assistive devices.

Endotracheal intubation: Endotracheal intubation is performed to secure the airway and provide mechanical ventilation in cases of respiratory failure or inability to maintain airway patency. Although dyspnea may require airway support, the key finding here strongly suggests a pneumothorax or hemothorax rather than primary airway obstruction.

Bronchoscopy: Bronchoscopy is a diagnostic and sometimes therapeutic procedure used to visualize the bronchial tree, remove foreign bodies, or evaluate airway lesions and bleeding. In a trauma setting with suspected pneumothorax, immediate decompression of the pleural space is required rather than visualization of the bronchial passages.

Pulmonary function test: Pulmonary function tests evaluate lung volumes, airflow, and gas exchange to diagnose chronic respiratory conditions such as asthma, COPD, or restrictive lung disease. These tests require patient stability and cooperation and are not performed in emergency trauma situations. Acute dyspnea with unilateral absent breath sounds indicates a life-threatening condition requiring rapid intervention.

Initiate teaching for client care after discharge: Initial client education, particularly discharge teaching, requires comprehensive knowledge of the client’s diagnosis, treatment plan, and learning needs. This responsibility involves assessment, planning, and evaluation of understanding, which are functions of the registered nurse.

Determine the need for urinary catheterizations: Determining whether a client requires urinary catheterization requires clinical judgment and assessment of the client’s condition, including bladder function, urinary retention, and risk of infection. This type of decision-making falls under the RN’s scope because it involves assessment and clinical evaluation.

Complete comprehensive assessments: A comprehensive assessment involves a full evaluation of the client’s physiological, psychological, and functional status, often performed during admission or when there is a change in condition. This level of assessment requires critical thinking and interpretation of findings, which are core responsibilities of the registered nurse.

Place the chair by the bed: Positioning the chair next to the bed can help facilitate a safe transfer, but it is not the priority immediately after the client is moved to a sitting position. After prolonged bedrest, clients are at high risk for orthostatic hypotension. The nurse should first assess the client’s tolerance to the position change before proceeding with transfer activities.

Support the client when rising: Providing physical support during standing is important to prevent falls; however, the client should not be assisted to stand immediately after sitting up following extended bedrest. Rapid changes in posture may lead to dizziness, syncope, or hypotension. The nurse must first determine the client’s physiologic response to sitting.

Offer a pair of nonskid socks: Nonskid socks help reduce the risk of slipping during ambulation or transfer and are an appropriate safety intervention. However, this action is relevant only after confirming that the client can tolerate sitting and is ready to proceed with standing or walking. The immediate priority is assessing the client’s response to the initial position change.

Before changing assignments, determine which staff members have fitted particulate filter masks: Particulate filter masks, such as N95 respirators, are required for airborne precautions, not droplet precautions. Bacterial meningitis is transmitted via large respiratory droplets, so requiring an N95 mask is unnecessary.

Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care: Droplet precautions only require a standard surgical mask when within close proximity to the client. Requiring an N95 fit for routine feeding or vital sign assessment imposes an unnecessary barrier to care and is not evidence-based.

Send the UAP to be fitted for a particulate filter mask immediately so the UAP can provide care to this client: Fitting a particulate filter mask is only required for airborne precautions, such as for tuberculosis or measles. Sending the UAP for N95 fitting delays essential care unnecessarily and is not supported by infection-control guidelines for droplet precautions.

Transient ischemic attack: A transient ischemic attack (TIA) involves a temporary disruption of cerebral blood flow, leading to sudden neurological deficits such as weakness, speech disturbances, or visual changes. While a TIA can cause motor symptoms, it is episodic, resolves within 24 hours, and is not characterized solely by tremor during voluntary movement.

Muscle flaccidity: Muscle flaccidity refers to decreased muscle tone and weakness, resulting in limp, soft, or floppy extremities. Tremors are an increase in involuntary movement, often with normal or increased tone, and are not consistent with flaccidity. Describing the client’s hands as flaccid would misrepresent the observed shaking.

Sensory dysfunction: Sensory dysfunction involves impaired perception of touch, pain, temperature, or proprioception. While some neurological conditions affecting sensation may contribute to tremors, the involuntary shaking during purposeful movement is a motor symptom rather than a primary sensory deficit. Recording it as sensory dysfunction would be inaccurate.