A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?
The client advances their right foot to meet their left foot.
The client maintains two points of support on the floor.
The client holds the cane in their left hand.
The client moves the cane forward 50.8 cm (20 in) when ambulating.
The Correct Answer is B
B. When using a quad cane, the client should always maintain two points of support on the floor: the cane and either the affected (left) or unaffected (right) leg. This ensures stability and support while walking.
A When using a quad cane, the client should advance their weaker (left) foot and then the stronger (right) foot. This allows the cane to provide support on the weaker side.
C. This action is correct for a client with left-sided hemiparesis. The quad cane should be held on the stronger side (right hand) to provide support for the weaker side (left leg).
D. This statement is unclear in terms of the context provided. However, typically when using a quad cane, the cane is moved forward a comfortable distance with each step to provide continuous support and balance. The exact distance may vary depending on the client's stride length and comfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. The appropriate action for a nurse to take would be to check for air leaks in the system. This can be done by clamping the tubing momentarily to see if the bubbling stops, which would suggest the presence of a leak.
A The drainage system should always be kept below the level of the chest and should not be raised or emptied unless specifically indicated.
C. Emptying the collection chamber is typically unnecessary unless it is nearing full capacity. Continuous bubbling in the water seal chamber does not indicate that the collection chamber needs immediate emptying.
D. Squeezing the tubing can disrupt the functioning of the drainage system and is not recommended. Drainage should flow passively into the collection chamber without external manipulation.
Correct Answer is B
Explanation
B. After a lumbar puncture, instructing the client to lie flat on their back for a period of time (often 1-2 hours) helps prevent complications such as headaches due to CSF leakage and promotes proper sealing of the puncture site.
A Monitoring blood glucose every 2 hours is not typically necessary immediately following a lumbar puncture unless the client has pre-existing diabetes or there are specific indications to monitor glucose levels
C Tingling in the extremities is not an expected or normal occurrence following a lumbar puncture. It could indicate neurological complications such as nerve irritation or damage, which would require prompt assessment and intervention.
D. The nurse should encourage adequate hydration unless contraindicated by the client's medical condition or specific post-procedure instructions.
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