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. "It sounds like you are exhausted."
This response demonstrates empathy and acknowledges the client's emotional state. The "E" in the NURSE mnemonic stands for "empathize," which involves recognizing and validating the client's feelings. By acknowledging that the client may be exhausted, the nurse shows understanding and empathy towards the client's experience of feeling overwhelmed.

B. "Tell me more about how you are feeling."
This response demonstrates active listening and encourages the client to express their emotions further. While important for therapeutic communication, it does not specifically address the client's feeling of being overwhelmed as directly as option A.

C. "You have so much to deal with. How can I be of help to you?"
This response demonstrates support and willingness to assist the client but does not directly address the client's reported feeling of being overwhelmed.

D. "It is impressive how you have managed to deal with the situation."
This response offers praise but does not directly address the client's reported feeling of being overwhelmed. It may also inadvertently minimize the client's feelings by focusing on their ability to cope rather than acknowledging their current emotional state.

A. Exposed bone B. Blood filled blisters C. Necrotic subcutaneous tissue D. Partial-thickness skin loss.

Correct Answer is C

Explanation

A) Exposed bone: Exposed bone is a manifestation of a stage 4 pressure ulcer, where full-thickness skin loss occurs, exposing muscle, tendon, or bone. In stage 3 pressure ulcers, the skin loss extends into the subcutaneous tissue, but it does not reach the level of exposing underlying structures like bone.

B) Blood-filled blisters: Blood-filled blisters can occur in various stages of pressure ulcers, but they are not specific to stage 3. They may be present in stage 1 or stage 2 pressure ulcers as well.

C) Necrotic subcutaneous tissue: This is the correct manifestation of a stage 3 pressure ulcer. Stage 3 pressure ulcers involve full-thickness skin loss with visible necrosis or damage to the subcutaneous tissue. The ulcer may appear as a deep crater with or without undermining of adjacent tissue.

D) Partial-thickness skin loss: Partial-thickness skin loss is characteristic of stage 2 pressure ulcers, where the ulcer extends through the epidermis and into the dermis but does not involve deeper tissue layers like the subcutaneous tissue.

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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?

Nursing Test Bank

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