A nurse is caring for a client.

Exhibit 1

Medical History

0800:

Client has a history of hyperlipidemia, rheumatoid arthritis, and hypertension.

Client has a BMI of 32.

Client has a family history of colon cancer.

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for heart disease? (Select all that apply.)

A. Swing-through gait:

The swing-through gait is a more advanced gait pattern used by clients with significant lower extremity weakness or paralysis. It involves swinging both crutches forward simultaneously, followed by swinging both legs forward past the crutches. This gait is not appropriate for a client who can only bear weight on one leg.

B. Three-point gait:

The three-point gait is typically used when one lower extremity is completely non-weight-bearing. It involves advancing both crutches and then swinging the affected leg through to meet the crutches. Since the client in this scenario can bear weight on one leg, the three-point gait is the most appropriate choice.

C. Four-point alternating gait

Four-point alternating gait
The four-point alternating gait involves a sequence of movements where each crutch and each leg move alternately. The sequence is as follows:

• Move the right crutch forward(injured side).
• Move the left foot forward(non-injured side).
• Move the left crutch forward(non-injured side).
• Move the right foot forward(injured side). This gait offers stability and control but requires more effort and coordination.

D. Two-point alternating gait:

The two-point alternating gait involves moving one crutch and the opposite lower extremity forward simultaneously, followed by moving the other crutch and the opposite lower extremity forward. This gait pattern is typically used by clients who have good balance and strength in both lower extremities. It may not provide enough stability and support for a client who can only bear weight on one leg.

A. A nurse administers a medication without first identifying the client.

Negligence refers to the failure to provide care that a reasonable and prudent person would normally perform in a similar situation, resulting in harm to the client. In this scenario, administering medication without first identifying the client constitutes negligence because it violates the standard of care expected of a nurse. Proper identification of the client is essential to ensure that the correct medication is administered to the right individual, preventing medication errors and potential harm.

B. A nurse begins a blood transfusion without obtaining consent from a client:

This situation involves a failure to obtain informed consent, which is a violation of the client's rights but does not necessarily constitute negligence. Negligence typically involves a failure to provide proper care rather than a failure to obtain consent.

C. An assistive personnel prevents a client from leaving the facility:

While preventing a client from leaving the facility without appropriate authorization may be inappropriate or a breach of the client's rights, it does not necessarily constitute negligence. Negligence involves a failure to provide care that meets the standard of care expected in a given situation.

D. An assistive personnel discusses client care in the facility cafeteria with visitors present:

This situation may involve a breach of confidentiality or privacy but does not constitute negligence unless the discussion leads to harm or adverse consequences for the client. Negligence typically involves a failure to provide care that results in harm or injury to the client.