A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?
Four-point.
Three-point.
Two-point.
Swing-through.
The Correct Answer is B
The correct answer is choice b. Three-point.
Choice A rationale:
The four-point gait is used when a client can bear weight on both legs. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. This gait provides maximum stability but is not suitable for non-weight-bearing conditions.
Choice B rationale:
The three-point gait is appropriate for clients who cannot bear weight on one leg. In this gait, both crutches and the affected leg move forward together, followed by the unaffected leg. This allows the client to keep weight off the injured leg while moving.
Choice C rationale:
The two-point gait is used when a client can bear partial weight on both legs. It involves moving one crutch and the opposite leg forward simultaneously, followed by the other crutch and leg. This gait is faster than the four-point gait but still provides some stability.
Choice D rationale:
The swing-through gait is used by clients who have good upper body strength and balance. It involves moving both crutches forward together and then swinging both legs forward past the crutches. This gait is not typically recommended for clients who need to keep weight off one leg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice d. Notify the charge nurse of the client’s concerns.
Choice A rationale:
Offering information about alternative therapies is not appropriate in this situation. The nurse’s role is to ensure the client understands the current procedure and to address their concerns, not to suggest alternatives unless directed by the healthcare provider.
Choice B rationale:
Contacting a family member to convince the client to change their mind is not ethical. The decision to proceed with surgery should be made by the client, based on their understanding and consent, not under pressure from family members.
Choice C rationale:
Telling the client the benefits of the surgery might be helpful, but it does not address the client’s lack of understanding about the procedure. The nurse should ensure the client has all the necessary information to make an informed decision.
Choice D rationale:
Notifying the charge nurse of the client’s concerns is the correct action. The charge nurse can facilitate further discussion with the surgeon to ensure the client receives the necessary information and support to make an informed decision. This ensures that the client’s autonomy and right to informed consent are respected.
Correct Answer is C
Explanation
The correct answer is choice C. Headache.
Choice A rationale:
Fluid overload is not a potential adverse effect of a lumbar puncture. A lumbar puncture involves the removal of cerebrospinal fluid (CSF) from the spinal canal, which wouldn't lead to fluid overload. This choice is not relevant to the procedure.
Choice B rationale:
Diarrhea is not a common adverse effect of a lumbar puncture. The procedure involves accessing the spinal canal and collecting CSF, which is not directly connected to the gastrointestinal system. Diarrhea is unrelated to the procedure.
Choice C rationale:
Headache is a potential adverse effect of a lumbar puncture. This is caused by the leakage of cerebrospinal fluid (CSF) through the puncture site, leading to a decrease in CSF pressure. This drop in pressure can cause a headache, particularly when the client sits or stands up. The headache is often described as severe and may be accompanied by neck pain and sensitivity to light. It usually resolves within a few days but can be managed with pain relief medications and plenty of fluids.
Choice D rationale:
Difficulty voiding is not a common adverse effect of a lumbar puncture. The procedure involves the lower back and spinal canal, and it doesn't directly affect the urinary system. This choice is unrelated to the procedure and its potential complications.
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