A client with osteoarthritis of the hips and knees has received instructions on how to use a walker for ambulation.
Which behavior observed by the nurse indicates the client understands the instructions?
The client uses the walker to get up from the chair and looks down at his feet to prevent falling.
The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first.
The client places her full weight on the walker with her arms while taking steps to prevent pressure on her lower extremity joints.
The client leans forward at a 60-degree angle while stepping into the walker but looks ahead at where he is going.
The Correct Answer is B
The client bears weight on both feet when moving the walker ahead and steps with the weaker leg first. This is the proper way to use a walker for ambulation, as it provides stability and reduces stress on the affected joints.
Choice A is wrong because the client should not look down at his feet to prevent falling, but rather look ahead at where he is going. Looking down can cause neck strain and loss of balance.
Choice C is wrong because the client should not place her full weight on the walker with her arms while taking steps, as this can cause upper extremity fatigue and injury. The client should use the walker as a support, not a crutch.
Choice D is wrong because the client should not lean forward at a 60-degree angle while stepping into the walker, as this can cause back pain and poor posture. The client should stand upright and move the walker forward about one step’s length at a time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Orthostatic hypotension noted with dangling.
This means that the client’s blood pressure drops when changing position from lying down to sitting or standing. This can cause symptoms such as paleness, sweating, rapid pulse, weakness, and dizziness.
The nurse should document this finding and report it to the physician.
Choice A is wrong because a normal reaction to a position change would not cause such severe symptoms.
Choice B is wrong because the gait belt applied is not a finding but an intervention.
Choice D is wrong because elevated blood sugar probable is not a finding but a speculation.
Choice E is wrong because spot accucheck obtained is not a finding but an action.
Choice F is wrong because fear of falling expressed by a client is not a finding related to the client’s vital signs or physical condition.
Choice G is wrong because provided reassurance is not a finding but a nursing measure.
Correct Answer is A
Explanation
Rhonchi. Rhonchi are low-pitched, rattling sounds that indicate mucus in the larger airways. They are most evident on expiration and may decrease after coughing.
Choice B is wrong because wheezes are high-pitched, squeaking sounds that indicate narrowed small air passages. They are usually heard on both inspiration and expiration.
Choice C is wrong because crackles are short, high-pitched popping sounds that indicate fluid or inflammation in the alveoli. They are usually heard on inspiration.
Choice D is wrong because pleural friction rubs are creaking or grating sounds that indicate inflammation of the pleura. They are usually heard on both inspiration and expiration and do not change with coughing.
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