The nurse is assessing the body alignment of an alert and mobile client. Which of the following is the first action the nurse should take?
a. Observe gait.
b. Put the client at ease.
c. Determine activity tolerance.
d. Determine range of joint motion.
B
The first step in assessing body alignment is to put the client at ease so that unnatural or rigid positions are not assumed.
When assessing body alignment, the nurse's first action is to put the client at ease. Later, the nurse may assess the client's gait to observe the client's balance, posture, and ability to walk without assistance.
Activity tolerance is the kind and amount of exercise or activity a person is able to perform. De-termining activity tolerance is not the first step in assessing a client's body alignment.
Assessing range of motion (ROM) is one of the first assessment techniques used to determine the degree of damage or injury to a joint. It is not the first step in assessing a client's body alignment.
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