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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?

A.

Moving both crutches with the stronger leg forward first.

B.

Supporting his body weight while leaning on the axillary crutch pads

C.

Stepping with his affected leg first when going up stairs

D.

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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Related Questions

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

Explanation

B, C, and E. The nurse should include the following statements in the teaching:.

    • You should eat foods that are low in fat. A low-fat diet can help reduce the amount of digestive enzymes your pancreas releases and prevent further inflammation and pain.
    • Notify your provider if you experience vomiting or diarrhea. These symptoms can lead to dehydration and malnutrition, which can worsen your condition and require hospitalization.
    • You should eat foods high in protein. Protein can help your body heal and repair damaged tissues. It can also prevent muscle wasting and weight loss, which are common complications of chronic pancreatitis.

Choice A is wrong because caffeine can stimulate the pancreas and increase pain and inflammation. Choice D is wrong because alcohol can damage the pancreas and trigger more attacks. People with chronic pancreatitis should avoid alcohol completely.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The nurse should recognize the client is experiencing preterm labor due to previous preterm birth.

Preterm labor is when regular contractions begin to open the cervix before 37 weeks of pregnancy. One of the risk factors for preterm labor is having a previous preterm delivery. The client’s history indicates that her last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation. The client’s current symptoms, such as lower back pain, pinkish vaginal discharge, uterine contractions and cervical dilation, also suggest that she is in preterm labor. Therefore, the nurse should recognize that the client is experiencing preterm labor due to previous preterm birth.

BMI, blood type and blood pressure are not causes of preterm labor in this case. BMI may be associated with preterm labor if it is too high or too low, but the client’s BMI is within the normal range for pregnancy. Blood type may cause Rh incompatibility if the mother is Rh negative and the baby is Rh positive, but the client’s blood type is Rh positive. Blood pressure may cause preeclampsia if it is too high, but the client’s blood pressure is normal. Abruptio placentae is a condition where the placenta separates from the uterine wall before delivery, which can cause vaginal bleeding, abdominal pain and fetal distress. The client does not have these signs.

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