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 A

Explanation

A. Applying a moisture barrier helps protect the skin from irritation and breakdown due to prolonged exposure to moisture.
B. Cleansing the skin with antibacterial soap and hot water may be too harsh and can contribute to skin irritation; gentle cleaning with a mild cleanser is preferable.
C. Toileting the client every 4 hours may not be frequent enough to prevent skin breakdown; a more frequent toileting schedule should be implemented.
D. Reducing the client's daily fluid intake is not a recommended intervention for urinary incontinence, as it may lead to dehydration and other health issues.

A. Frequency of previous vital sign measurement B. Effectiveness of the last dose of pain medication C. Number of family members who have visited D. Time of the client's last bath

Correct Answer is B

Explanation

A. The frequency of previous vital sign measurements may be important but is not the most critical information to communicate during a transfer.
B. The effectiveness of the last dose of pain medication is crucial information for the receiving facility to manage the client's pain appropriately.
C. The number of family members who have visited is important for emotional support but may not be the priority for the receiving facility.
D. The time of the client's last bath is relevant but may not be as critical as information related to pain management during the hand-off report.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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