Author Question: The nurse is assessing a patient's ability to walk. Which of the following should be assessed first ... (Read 61 times)

JGIBBSON · **on:** Jul 22, 2018

The nurse is assessing a patient's ability to walk. Which of the following should be assessed first for this patient?

a. Walking c. Standing
b. Sitting d. Turning

Question 2

The nurse is caring for a client who received a diagnosis of breast cancer several weeks ago and was admitted to the hospital for a radical mastectomy to be followed by initiation of chemotherapy.

The nurse is aware of the client's poor prognosis secondary to multiple metastasis sites. The client tells the nurse, I'm a fighter and I am going to beat this cancer and do whatever it takes to survive.. The nurse's best response is aimed at: 1. Helping the client face the reality of the situation and the low chance of survival.
2. Supporting the client's determination and providing information to promote recovery.
3. Encouraging the client to prepare for death while fighting for survival.
4. Talking with the family about the client's unrealistic expectations.

Jayson · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
Progressive exercises and activities that promote independent mobility include: turning, sitting, standing, and finally walking.

Answer to Question 2

2. Supporting the client's determination and providing information to help promote recovery.

Rationale:
This client is in the earliest stages of cancer treatment, with removal of the primary tumor about to take place. The nurse's role is to support this client's optimism and help in fighting the disease by teaching about nutrition and other supportive actions the client can take to minimize complications of treatment. While the prognosis may be poor, the outcome is not absolute, and the client's wish to do whatever is necessary to survive should be supported. Emphasizing the low survival rate, encouraging the client to prepare for death, and talking with the family about the client's unrealistic expectations would not support the client's optimism.