The nurse is assessing the body alignment of an alert and mobile clien

The nurse is assessing the body alignment of an alert and mobile client. The first action that the nurse should take is to:

1. Observe gait
2. Put the client at ease
3. Determine activity tolerance
4. Determine range of joint motion

ANSWER

ANS: 2
The first step in assessing body alignment is to put the client at ease so unnatural or rigid posi-tions are not assumed. When assessing body alignment, the first action of the nurse 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. It is not the first step in assessing a client’s body alignment. Assessing ROM is one of the first assessment techniques used to determine the degree of dam-age or injury to a joint. It is not the first step in assessing a client’s body alignment.