The nurse is assessing the body alignment of an alert and mobile patient. Which one of the following is the first action the nurse should take?
a. Observe gait.
b. Put the patient at ease.
c. Determine activity tolerance.
d. Determine range of joint motion.
B
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A When assessing body alignment, the nurse's first action is to put the patient at ease. Later, the nurse can assess the patient's gait to observe the patient's balance, posture, and ability to walk without assistance.
B The first step in assessing body alignment is to put the patient at ease so that unnatural or rigid positions are not assumed.
C Activity tolerance is the kind and amount of exercise or activity a person is able to perform. Determining activity tolerance is not the first step in assessing a patient's body alignment.
D 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 patient's body alignment.
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