A nurse is assessing a patient’s ability to use a walking cane.
Which of the following observations would indicate that the patient is using the cane correctly?

Choice A rationale

This statement is incorrect. Advance directives do not allow the court to overrule an adult client’s refusal of medical treatment. They are legal documents that provide instructions for medical care and only go into effect if the individual cannot communicate their own wishes.

Choice B rationale

This statement is correct. Advance directives indicate the form of treatment a client is willing to accept in the event of a serious illness. They allow individuals to express their preferences about medical treatment at some point in the future, should they become unable to communicate their wishes.

Choice C rationale

This statement is incorrect. Advance directives do not permit a client to withhold medical information from health care personnel. They are used to communicate the individual’s wishes about medical treatment to their healthcare providers and family.

Choice D rationale

This statement is incorrect. Advance directives do not specifically allow health care personnel in the emergency department to stabilize a client’s condition. They are used to guide choices for doctors and caregivers if the individual is terminally ill, seriously injured, in a coma, in the late stages of dementia or near the end of life.

The correct answers are Choices A, B, and C.

Choice A rationale: Passive range-of-motion exercises should be performed more frequently than once each day to maintain joint mobility, prevent contractures, and stimulate circulation. Performing them only once daily is inadequate for a client with paraplegia who is immobile.

Choice B rationale: Nonblanchable erythema is a sign of a stage 1 pressure ulcer, indicating that the skin is at risk of further breakdown and infection. Immediate intervention is required to prevent progression to more severe pressure injuries.

Choice C rationale: Plantar flexion contractures can lead to significant long-term disability and complications, such as difficulty in ambulation and pain. These contractures require intervention through more frequent range-of-motion exercises, splinting, or physical therapy to prevent worsening.

Choice D rationale: Pedal pulses that are 2+ bilaterally are within normal limits and indicate adequate peripheral circulation. This finding does not require intervention.