Difficulty: Medium
Average Score: 92%
Simulated
The nurse is performing the 'Timed Get Up and Go (TUG)' assessment. Which actions will the nurse take? (Select all that apply.)
Correct answer
C,D,F
Rationale
The correct answers are C, D, and F.
C: Instructing the patient to walk 10 feet quickly and safely is a key component of the TUG test to assess mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is important to evaluate balance and stability during the test.
F: Beginning counting after giving instructions ensures an accurate timing of the patient's performance.
Incorrect choices:
A: Ranking a patient as high risk for falls after taking 18 seconds is not accurate as the cutoff time for increased fall risk is typically 12-14 seconds.
B: Teaching the patient to rise from a straight back chair using arms for support is not part of the TUG assessment and may not provide accurate information about the patient's mobility and fall risk.
C: Instructing the patient to walk 10 feet quickly and safely is a key component of the TUG test to assess mobility and fall risk.
D: Observing for unsteadiness in the patient's gait is important to evaluate balance and stability during the test.
F: Beginning counting after giving instructions ensures an accurate timing of the patient's performance.
Incorrect choices:
A: Ranking a patient as high risk for falls after taking 18 seconds is not accurate as the cutoff time for increased fall risk is typically 12-14 seconds.
B: Teaching the patient to rise from a straight back chair using arms for support is not part of the TUG assessment and may not provide accurate information about the patient's mobility and fall risk.