A nurse completes an assessment of a client just admitted from the emergency department. Which assessment finding(s) should concern the nurse? Select all that apply.

A. “I will use the cane to support all of my weight when walking.": A cane is meant to provide partial support and improve balance, not bear the client’s full weight. Relying entirely on the cane can cause instability and increase the risk of falls.

B. "I will make sure my elbow is bent slightly when I hold the cane.": Proper cane use requires a slight elbow flexion of about 20–30 degrees. This position ensures optimal support, reduces strain on the shoulder and wrist, and promotes safe ambulation.

C. "I will move the strong leg up the stairs first, then the cane, and then the weak leg.": When using a cane, it should move simultaneously with the weaker leg while ascending or descending stairs to provide support. Moving the strong leg first without coordinating the cane can compromise safety.

D. “I will hold the cane on the weak side of my body to support it.": The cane should be held on the strong side to provide counterbalance and allow the weaker leg to bear weight safely. Holding it on the weak side decreases stability and increases fall risk.

A. Implement a fluid restriction: Fluid restriction is indicated only in specific conditions such as heart failure or renal failure. Routine postoperative clients typically require adequate hydration to support healing, so restricting fluids is not appropriate.

B. Provide a high-protein diet: Protein is essential for wound healing, tissue repair, and maintaining immune function after surgery. A high-protein diet supports collagen formation, prevents muscle loss, and enhances recovery. This intervention is a standard component of postoperative nutrition care.

C. Encourage high caffeine beverages: Caffeine can lead to dehydration and increased heart rate, which may complicate recovery. High caffeine intake does not support healing and is not recommended as a postoperative nutrition intervention.

D. Limit the intake of citrus fruits: Citrus fruits provide vitamin C, which supports collagen synthesis and immune function. Limiting them is unnecessary unless there is a specific allergy or gastrointestinal intolerance. Their inclusion is generally beneficial for surgical recovery.