A nurse is providing home safety information for an older adult client who uses a cane. Which of the following statements should the nurse include in the teaching?
You should advance your weak leg forward to the cane, then move your strong leg
You should advance the cane 12 to 14 inches before taking a step.
The cane’s height should be the same as the distance from the floor to the crest of your hip bone?
You should hold the cane in your weak hand when ambulating
The Correct Answer is C
A. You should advance your weak leg forward to the cane, then move your strong leg:
Advancing the weak leg first and then the strong leg is not the proper technique for using a cane. The correct method is to hold the cane on the stronger side and move the cane and the weaker leg forward together, followed by the stronger leg.
B. You should advance the cane 12 to 14 inches before taking a step:
Advancing the cane 12 to 14 inches is too far. The cane should be advanced approximately 6 to 10 inches to maintain balance and support.
C. The cane’s height should be the same as the distance from the floor to the crest of your hip bone:
The correct height for a cane is when the handle is at the level of the wrist when the user is standing with the arm hanging naturally at their side. This typically corresponds to the distance from the floor to the greater trochanter (hip bone). This ensures the cane provides the right amount of support and reduces the risk of strain or imbalance.
D. You should hold the cane in your weak hand when ambulating:
The cane should be held in the stronger hand, not the weak hand. This allows the cane to provide support to the weaker side of the body and helps to balance the weight distribution more effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Chronic drainage of fluid through the incision site:
While chronic drainage of fluid through the incision site can be a sign of wound complications, such as infection or poor wound healing, it is not as specific an indicator of impending wound dehiscence as the patient's report of "something giving way."
B. Report by patient that something has given way:
A patient reporting that something has given way is a significant indicator of potential wound dehiscence. Wound dehiscence refers to the partial or complete separation of the layers of a surgical wound, which can occur due to various factors such as poor wound healing, infection, or increased intra-abdominal pressure. Patients may describe a sensation of "something giving way" or "popping" if the wound starts to separate.
C. Drainage that is odorous and purulent:
Odorous and purulent drainage from an incision site may indicate an infection, which can contribute to wound dehiscence. However, this finding alone may not necessarily indicate immediate wound dehiscence.
D. Protrusion of visceral organs through a wound opening:
Protrusion of visceral organs through a wound opening is a severe complication known as evisceration, which is the most advanced stage of wound dehiscence. While this finding is indicative of a significant wound complication, it typically occurs after the initial separation of wound layers. Therefore, it is not an early sign that would alert the nurse to potential wound dehiscence
Correct Answer is C
Explanation
A. Helping the client select a low-salt diet:
This option is not directly related to addressing tenacious bronchial secretions in COPD. While a low-salt diet may be beneficial for managing conditions like hypertension or heart failure, it does not directly influence the viscosity of bronchial secretions.
B. Administering oxygen via nasal cannula at 2 L/min:
Oxygen therapy is important for clients with COPD, especially during exacerbations or periods of hypoxemia. However, in this scenario, the client's primary concern is tenacious bronchial secretions, and oxygen therapy alone may not effectively address this issue.
C. Encouraging the client to drink 2 to 3 L of water daily:
This is the correct answer. Increasing fluid intake helps to hydrate the mucous membranes and thin bronchial secretions, making them easier to expectorate. Adequate hydration is essential for optimizing the clearance of secretions in clients with COPD.
D. Maintaining a semi-Fowler's position as often as possible:
While maintaining a semi-Fowler's position can improve respiratory mechanics and reduce dyspnea in clients with COPD, it does not directly address the issue of tenacious bronchial secretions. This position primarily helps in optimizing lung expansion and facilitating easier breathing.
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