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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.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

Moving both crutches with the stronger leg forward first is incorrect for a three-point gait. This describes a two-point gait, which is used when a client can bear weight on both legs. In a three-point gait, the client bears weight on the unaffected leg and the crutches, not the stronger leg.
This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.

Choice B rationale:

Supporting his body weight while leaning on the axillary crutch pads is also incorrect. This can lead to nerve damage in the armpits and should be avoided.
The weight should be distributed through the hands and wrists, not the armpits.

Choice C rationale:

Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous. The client should lead with the stronger leg when going up stairs to maintain balance and control.

Choice D rationale:

Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait. This allows for proper weight distribution, balance, and control of the crutches.
It also helps to prevent fatigue and strain in the arms and shoulders.

Key points to remember about the three-point gait:

Weight is borne on the unaffected leg and the crutches, not the affected leg.
The crutches and the unaffected leg move forward together, followed by the affected leg.
The client should look ahead, not down at their feet.
The client should take small, even steps.
The client should rest as needed.

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Correct Answer is A

Explanation

The correct answer is choice A. Implement firm but flexible boundaries in their relationship.

This is because boundaries can help the client and family to respect each other’s roles, needs and preferences, and to avoid role confusion, resentment or guilt. Boundaries can also promote independence and self-care for the client, as well as prevent caregiver burnout for the family.

Choice B is wrong because minimizing open discussion regarding the changes can lead to misunderstanding, frustration or isolation. The client and family should communicate openly and honestly about their feelings, expectations and challenges, and seek support when needed.

Choice C is wrong because authoritative communication from the adult child can create a power imbalance, undermine the client’s autonomy and dignity, or cause conflict or resistance. The client and family should use respectful and collaborative communication, and involve the client in decision-making as much as possible.

Choice D is wrong because decreasing socialization with extended relatives can reduce the client and family’s support network, increase their stress or loneliness, or limit their opportunities for meaningful activities. The client and family should maintain contact with their relatives and friends, and participate in social or recreational activities that they enjoy.

A. Call in additional medical-surgical unit nursing care staff B. Act as a liaison between the facility and the media C. Determine the medical needs of incoming clients through the emergency department. D. Recommend to the provider specific acute care clients for discharge.

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: While additional staff may be needed, the primary focus during a mass casualty event is triage and immediate care. Choice B rationale: Media relations are important, but the nurse's priority is direct patient care. Choice C rationale: Assessing incoming clients and determining their medical needs is crucial for prioritizing care and allocating resources effectively. Choice D rationale: Discharging stable clients may be necessary in extreme circumstances, but it is not the immediate priority. The focus should be on providing care to the influx of injured patients.

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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?

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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?