17-year-old male arrives at the emergency department following playing baseball. He slid into a base, felt a 'pop', and had pain in his right ankle.
The client reports pain of 7 out of 10 in his right ankle, which is described as throbbing. Right pedal pulse was 2+, and the sensation was intact.
The client had a limited and painful range of motion in his ankle. Significant swelling and bruising in the ankle were observed.
The emergency department nurse cares for a client with right ankle pain.
Complete the statement below:
While teaching the client how to use crutches, the nurse should instruct the client to ambulate using the
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Choice A rationale: A three-point gait is used when one leg is weaker or injured and cannot bear weight. The client should place the crutches about 12 inches in front of the feet and lean forward on the crutches. Then, the client should lift the injured leg and
swing the body forward between the crutches, landing on the uninjured leg. The client should not put any weight on the injured ankle, as ordered by the physician.
Choice B rationale: A four-point gait is used when both legs can bear some weight, but one is weaker than the other.
Choice C rationale: A swing-through gait is used when both legs can bear weight, but need assistance with balance and coordination.
Choice D rationale: A two-point gait is used when both legs have equal strength and can bear full weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: This test is not specific for confirming osteoporosis.
Choice B rationale: This test is called a bone mineral density (BMD) test or a dual-energy X-ray absorptiometry (DXA) scan. It measures how much calcium and other minerals are in a segment of bone.
Choice C rationale: This test is not specific for confirming osteoporosis.
Choice D rationale: This test is not specific for confirming osteoporosis.
Correct Answer is A
Explanation
Choice A rationale: In ALS, impaired physical mobility due to decreased motor agility and the inability to ambulate is a direct consequence of the disease.
Choice B rationale: Hopelessness might be a possible emotional response but doesn't address the client's physical limitations due to ALS.
Choice C rationale: Caregiver role strain is related to the family's ability to manage caregiving responsibilities and is not the primary concern for the client's physical mobility.
Choice D rationale: Impaired memory is not the primary issue in ALS; the client's inability to ambulate due to decreased motor function is the main focus for this nursing diagnosis.
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