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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) An older adult who is confused and has urinary frequency:
This client is at the greatest risk for a fall due to several factors. Confusion increases the likelihood of disorientation and impaired judgment, leading to accidents. Urinary frequency may necessitate frequent trips to the bathroom, increasing the chances of falls, especially if the client is disoriented or unsteady on their feet.

B) An older adult with hearing impairment:
While hearing impairment can contribute to a fall risk by limiting the client's ability to hear warnings or instructions, it may not pose as immediate a risk as confusion and urinary frequency, which directly affect mobility and judgment.

C) A client who has a dressing on his foot due to a pressure ulcer:
While having a dressing on the foot due to a pressure ulcer increases the risk of falls by potentially affecting the client's gait and balance, it may not be as significant a risk factor as confusion and urinary frequency, which directly impact the client's ability to safely navigate their environment.

D) A client who has osteoarthritis and uses a walker:
Although osteoarthritis and the use of a walker can contribute to mobility issues and an increased risk of falls, they may not present as immediate a risk as confusion and urinary frequency, which can lead to more unpredictable and hazardous situations.

A. A client who has had a cerebrovascular accident B. A client who has had radiation therapy for head and neck cancer C. A client who is 4 hr postoperative following a leg amputation with general anesthesia D. A client who has lactose intolerance E. A client who has had prolonged diarrhea

Correct Answer is ["A","B","C"]

Explanation

A) A client who has had a cerebrovascular accident:
Clients who have had a cerebrovascular accident (stroke) often suffer from dysphagia (difficulty swallowing) due to impaired muscle control or sensory deficits. This makes them more susceptible to aspiration, as food or liquid can enter the airway instead of the esophagus.

B) A client who has had radiation therapy for head and neck cancer:
Radiation therapy in the head and neck area can cause damage to tissues, leading to mucositis, fibrosis, and reduced salivary flow, all of which can impair swallowing function. This increases the risk of aspiration because the normal mechanisms that protect the airway during swallowing may be compromised.

C) A client who is 4 hr postoperative following a leg amputation with general anesthesia:
General anesthesia can depress the gag and cough reflexes and impair coordination of the muscles involved in swallowing, making it more difficult for the client to protect their airway. This increased risk of aspiration is particularly relevant in the immediate postoperative period when the effects of anesthesia may still be present.

D) A client who has lactose intolerance:
Lactose intolerance primarily affects the digestive system and does not directly impact the mechanics of swallowing or increase the risk of aspiration. This condition leads to gastrointestinal symptoms such as bloating, diarrhea, and abdominal pain when consuming lactose-containing foods, but it does not increase the risk of food or liquid entering the airway during eating.

E) A client who has had prolonged diarrhea:
Prolonged diarrhea can lead to dehydration and electrolyte imbalances, but it does not directly affect the swallowing mechanism or increase the risk of aspiration. The primary concern with prolonged diarrhea is fluid and electrolyte management rather than an increased risk of aspiration during eating.

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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?

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