A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture.
Which of the following actions by the client indicates an understanding of the teaching?
Moving both crutches with the stronger leg forward first.
Supporting his body weight while leaning on the axillary crutch pads.
Stepping with his affected leg first when going up stairs.
Positioning both hands on the grips with his elbows slightly flexed.
The Correct Answer is A
This indicates that the client understands how to use the crutches properly and avoid injury to the nerves and blood vessels in the axillae. The client should also maintain a tripod position before walking, which means keeping the crutches about 15 cm (6 inches) in front of the feet and 15 cm to the side of each foot.
Choice B is wrong because supporting his body weight while leaning on the axillary crutch pads can cause nerve damage and impaired circulation in the axillae. The client should support his weight on his hands, not his armpits.
Choice C is wrong because stepping with his affected leg first when going up stairs can cause further injury to the fractured tibia. The client should step with his unaffected leg first when going up stairs, and with his affected leg first when going down stairs.
Choice D is wrong because moving both crutches with the stronger leg forward first is not a three-point gait, but a four-point gait. A three-point gait involves moving both crutches and the affected leg forward together, followed by the unaffected leg.
According to Physiopedia, a three-point gait pattern is used when one of the lower extremities is unable to fully bear weight (due to fracture, amputation, joint replacement etc). There are three points of contact with the floor: the crutches serve as one point, the involved leg as the second point, and the uninvolved leg as the third point. Both crutches move forward, the affected limb then steps up to the crutches.
Based on this description, the correct answer is a. Moving both crutches with the stronger leg forward first. This action demonstrates that the client understands how to use the crutches and the affected leg as one unit, and how to maintain stability and balance. The other options are incorrect because:
- b. Supporting his body weight while leaning on the axillary crutch pads can cause nerve damage and reduce circulation in the axilla area
- c. Stepping with his affected leg first when going up stairs can cause further injury to the fracture site and increase the risk of falling.
- d. Positioning both hands on the grips with his elbows slightly flexed is a general guideline for crutch fitting, but it does not indicate an understanding of the three-point gait pattern specifically
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This action requires intervention by the staff nurse because waiting for 2 minutes between suctions is too long and can cause hypoxia, increased secretions, and infection. The recommended time interval between suctions is 30 to 60 seconds.
Choice A is wrong because Inserts the catheter without applying suction.
This is a correct action by the newly licensed nurse because applying suction while inserting the catheter can cause trauma to the tracheal mucosa. Suction should only be applied while withdrawing the catheter.
Choice C is wrong because Applies suction for 15 seconds. This is a correct action by the newly licensed nurse because applying suction for 15 seconds is within the recommended time limit of 10 to 15 seconds. Applying suction for longer than 15 seconds can cause hypoxia, bleeding, and cardiac arrhythmias.
Choice D is wrong because Encourages the client to cough during suctioning.
This is a correct action by the newly licensed nurse because encouraging the client to cough during suctioning can help loosen and mobilize secretions, making suctioning more effective and less traumatic.
Correct Answer is A
Explanation
This is because the AP’s statement constitutes an intentional tort, which is a wrong that the defendant knew or should have known would be caused by their actions. An assault is defined as intentionally putting another person in reasonable apprehension of an imminent harmful or offensive contact.
The AP’s threat of using restraints and force-feeding the client could cause the client to fear for their safety and dignity, which is an assault.
Choice B is wrong because Battery is wrong because battery is defined as intentional causation of harmful or offensive contact with another person without that person’s consent.
The AP did not actually touch the client or carry out the threat, so there was no battery.
Choice C is wrong because Negligence is wrong because negligence is an unintentional tort, which occurs when the defendant’s actions or inactions were unreasonably unsafe.
The AP did not act or fail to act in a way that breached the standard of care or caused harm to the client, so there was no negligence.
Choice D is wrong because Malpractice is wrong because malpractice is a type of negligence that involves a professional failing to perform their duties according to the standards of their profession.
The AP did not perform any professional duty or service that was below the standard of care or caused harm to the client, so there was no malpractice.
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