Which of the following actions should the nurse perform before a client with impaired physical mobility gets up?

Correct Answer: B

Rationale: In this scenario, the correct action the nurse should perform before a client with impaired physical mobility gets up is to apply an abdominal binder (Option B). The rationale behind this is that an abdominal binder provides support to the abdomen and lower back, which can help stabilize the client's core and provide additional support when transitioning from sitting to standing. This support can prevent strain on the client's muscles and reduce the risk of falls or injuries during the transfer process. Now, let's discuss why the other options are incorrect: A) Using parallel bars or a walker may be appropriate for some clients with impaired physical mobility, but in this specific context of a client preparing to get up, the focus should be on providing support to the core and lower back, which an abdominal binder can achieve more effectively. C) Using incontinence pads is not directly related to assisting a client with impaired physical mobility in getting up. While managing incontinence is important, it is not the immediate concern when helping a client transition from sitting to standing. D) Using a footboard is typically used to prevent foot drop in clients who are immobile or bedridden for extended periods. While a footboard can be beneficial in certain situations, it is not the most appropriate intervention to help a client with impaired physical mobility get up. In an educational context, understanding the importance of proper body mechanics, support devices, and assistive equipment in managing clients with impaired physical mobility is crucial for nurses. By selecting the correct intervention, such as applying an abdominal binder in this case, nurses can enhance patient safety, prevent injuries, and promote effective mobility for their clients.

Correct Answer: D

Rationale: In planning community education for the prevention of spinal cord injuries, targeting adolescent and young adult men (Option D) is crucial. This group is at higher risk due to engaging in more risky behaviors, such as sports activities, driving recklessly, and participating in activities with a higher likelihood of injury. Educating them about injury prevention strategies, safe practices, and the consequences of spinal cord injuries can help reduce the incidence rate. Older men (Option A) are also at risk for spinal cord injuries, but they may already be more aware of safety measures and have developed safer habits over time. Teenage girls (Option B) and elementary school-age children (Option C) are generally not as high-risk groups for spinal cord injuries compared to adolescent and young adult men. While education on injury prevention is important for all age groups, targeting the group with the highest risk will have a more significant impact on reducing the overall incidence of spinal cord injuries in the community. In an educational context, it is important to tailor the information to the specific group being targeted. For adolescent and young adult men, using relatable examples, real-life stories, and interactive activities can help engage them in the learning process. Emphasizing the long-term impact of spinal cord injuries on their quality of life and independence can also motivate them to adopt safer behaviors. By focusing on this high-risk group, nurses can effectively contribute to injury prevention efforts in the community.

Correct Answer: C

Rationale: In this scenario, the correct first action for the nurse to take is option C: assess lung sounds and respiratory rate and depth. This is the priority because the patient's poor cough with diaphragmatic breathing indicates potential respiratory compromise. By assessing lung sounds and respiratory parameters, the nurse can gather crucial information to determine the extent of respiratory distress and identify any immediate interventions needed. Option A (institute frequent turning and repositioning) is not the immediate priority when a patient is showing signs of respiratory distress. While repositioning is important for overall patient care, addressing the respiratory issue takes precedence. Option B (use tracheal suctioning to remove secretions) could potentially further compromise the patient's respiratory status if not done judiciously and based on a thorough assessment. Without knowing the exact nature of the respiratory distress, suctioning may not be the most appropriate initial action. Option D (prepare the patient for endotracheal intubation and mechanical ventilation) is a drastic intervention that should only be considered after a comprehensive assessment and if the patient's respiratory status continues to deteriorate despite other interventions. This option is not the first step in addressing the patient's current presentation. In an educational context, understanding the rationale behind prioritizing interventions based on assessment findings is crucial for nurses to provide safe and effective care. Developing critical thinking skills to prioritize actions based on assessment data is a fundamental aspect of nursing practice, especially in emergency situations such as respiratory distress in patients with spinal cord injuries.

Correct Answer: D

Rationale: The correct answer is D) Vertebrae become more compressed with thinning of intervertebral discs. As individuals age, the intervertebral discs between the vertebrae lose water content and elasticity, leading to decreased disc height. This compression causes the spine to shorten, resulting in a decrease in overall height. Option A, decreased muscle mass resulting in a stooped posture, is incorrect because while muscle mass can decrease with age, it does not directly lead to a significant loss in height. Option B, loss of cartilage in the knees and hip joints causing a loss of height, is incorrect as the question pertains to overall height loss, not localized joint issues. Option C, long bones becoming less dense and shortening as bone tissue compacts, is incorrect because long bones do not significantly contribute to the height loss observed in aging individuals. Understanding the physiological changes that occur with aging is crucial for healthcare professionals when assessing and educating older adults. By explaining the specific mechanism of vertebral compression and disc thinning, nurses can better address concerns related to height loss in the elderly population and provide appropriate guidance on preventive measures and management strategies.

Correct Answer: C

Rationale: The correct answer is C) Perform stretching and warm-up exercises before exercise. This is the best way to prevent musculoskeletal injuries during physical exercise because stretching helps to increase flexibility, improve circulation, and reduce the risk of muscle strains and tears. Warm-up exercises also prepare the muscles and joints for more intense activity, helping to prevent injuries. Option A) Increase muscle strength with daily isometric exercise is incorrect because while muscle strength is important for overall fitness, isometric exercises may not adequately prepare the muscles for the specific movements involved in physical exercise. Option B) Avoid exercising on concrete or hard pavement surfaces is incorrect because the surface on which one exercises is not the primary factor in preventing musculoskeletal injuries. Proper technique, warm-up, and stretching are more important. Option D) Wrap susceptible joints with elastic bandages or adhesive tape before exercise is incorrect because relying on external support like bandages does not address the underlying issue of muscle flexibility and strength, which are crucial for injury prevention. In an educational context, it is important for individuals to understand the rationale behind injury prevention strategies to promote safe and effective exercise habits. Teaching proper warm-up and stretching techniques can empower individuals to take an active role in safeguarding their musculoskeletal health during physical activity.