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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Having the guard sign a release of information form may not be appropriate in an emergency situation, and immediate action is needed to address the injury.
B. Telling the guard to submit an inmate inquiry form to the warden may delay necessary medical intervention in an emergency.
C. Completing an incident report is appropriate to document the situation and the care provided It is not necessary to disclose the inmate's HIV status in the report.

D. Instructing the guard to ask the inmate is not a proper approach to handling a medical emergency. The nurse should focus on providing immediate care to the injured inmate.

A. Keep the client's bed linens dry. B. Apply an alcohol-water solution to the client's skin. C. Encourage the client to drink 1,500 mL of fluid per day. D. Apply ice packs to the groin.

Correct Answer is A

Explanation

A. Keeping the client's bed linens dry helps maintain the client's comfort and prevents chilling associated with damp linens.
B. Applying an alcohol-water solution may increase evaporative cooling and is not a standard intervention for fever.

C. Encouraging increased fluid intake is appropriate to promote hydration, but the specific amount should be individualized based on the client's condition and needs.
D. Applying ice packs to the groin is not a recommended site for cooling and may cause discomfort. The choice of cooling measures should be appropriate and based on the healthcare provider's orders or institutional protocols.

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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?

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