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. Family visits should be limited to 30 minutes per day to minimize their exposure.
A It should be worn consistently by the nurse caring for the client with the radiation implant to monitor their radiation exposure. Giving it to the oncoming nurse at the end of the shift is not appropriate because it does not provide real-time monitoring of radiation exposure for the nurse during their shift.
C. Soiled linens should be kept in the room until the radioactive source is removed to prevent the spread of contamination
D. One should never touch it directly; instead, use long-handled forceps and place it in a lead-lined container for safe disposal.
Correct Answer is ["B","D","E","F","G"]
Explanation
Echocardiogram results would provide information about the structure and function of the heart, particularly regarding any changes in cardiac function or wall motion abnormalities that might have been detected during the acute phase. It does indicate signs of improvement.
B. Blood pressure is an important vital sign that reflects cardiovascular status. In the context of acute coronary syndrome or myocardial infarction, a stable or improving blood pressure indicates adequate perfusion to vital organs, including the heart. A decrease in blood pressure from hypertensive levels seen earlier could indicate stabilization of the client's condition.
C. Urinary output is a critical indicator of renal perfusion and function. During acute illness, including cardiac events, decreased urinary output can indicate poor perfusion due to decreased cardiac output or hypoperfusion. In this scenario the output is still inadequate.
D. Pain level, specifically chest pain in the context of acute coronary syndrome, is a subjective indicator of the client's cardiac status. A reduction in pain intensity, as reported by the client, can indicate that the treatment, such as nitroglycerin for angina, is effective in relieving myocardial ischemia. Therefore, a decrease in pain level suggests improvement in the client's cardiac condition.
E. Respiratory rate is another vital sign that reflects the client's respiratory effort and overall respiratory status. In the context of acute cardiac events, respiratory rate can increase due to pain, anxiety, or respiratory distress. A decrease in respiratory rate suggests improved respiratory comfort and potentially reduced cardiac workload, indicating improvement in the client's condition.
F. Heart rate is a crucial vital sign that reflects cardiac workload and rhythm. In acute coronary syndrome, tachycardia is often present due to sympathetic stimulation and the body's response to myocardial ischemia. A decrease in heart rate suggests that the client's cardiac workload has decreased, possibly indicating improved myocardial perfusion and stability.
G. Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood, which is essential for tissue oxygenation. In acute cardiac events, hypoxemia can occur due to impaired cardiac function or respiratory compromise. Improvement in oxygen saturation indicates improved tissue oxygenation, possibly due to effective management of cardiac function or respiratory support.
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