A nurse is observing a client who has right-sided weakness ambulate using a cane. Which of the following actions by the client should alert the nurse that further teaching is necessary?
The client holds the cane on the affected side.
The client keeps two points of support on the ground.
The client advances the cane before moving the unaffected leg.
The client supports his weight on both legs when moving the cane forward.
The Correct Answer is A
A) The client should hold the cane on the unaffected side to provide support for the affected side, which is weaker. Holding the cane on the affected side does not offer the necessary support and balance needed during ambulation, indicating a need for further teaching.
B) Keeping two points of support on the ground, such as one foot and the cane or both feet, is a safe practice that ensures stability while ambulating, so no further teaching is necessary for this action.
C) Advancing the cane before moving the unaffected leg is the correct technique. The cane should be moved first, followed by the affected leg, and then the unaffected leg, to maintain balance and support.
D) Supporting weight on both legs when moving the cane forward is appropriate as it provides a stable base and prevents the client from falling, indicating that the client understands the correct use of the cane.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Holding the dropper 1/2 inch (1 cm) above the ear canal during administration (option A) is indeed the correct action when administering otic medications. This distance helps to ensure that the medication is properly instilled into the ear canal without touching the dropper tip to the skin or ear canal, reducing the risk of contamination.
B. Placing a cotton ball into the inner ear canal is not necessary following otic administration. It may cause unnecessary discomfort to the client.
C. Straightening the ear canal by pulling the auricle down and back can make the medication trickle out of the ear. It should be held outward and upward.
D. Applying pressure to the nasolacrimal duct is a technique used for ophthalmic medications, not otic medications.
Correct Answer is A
Explanation
A. Monitoring the client at least once every hour is an appropriate safety precaution to assess the client's condition and prevent falls.
B. Assigning the client to a private room may not directly address the risk of falls and may not be necessary for fall prevention.
C. Requesting a PRN prescription for restraints should not be the first line of defense for fall prevention and should only be considered when other interventions are ineffective or inappropriate.
D. Keeping four side rails up while the client is in bed can be a restraint and may increase the risk of injury. It is not a recommended approach for fall prevention.
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