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?

Positioning both hands on the grips with his elbows slightly flexed

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

Answer and Explanation

The Correct Answer is A

A.   When using crutches, the client should position both hands on the grips with the elbows slightly flexed for proper support and balance.
B.   In the three-point gait, the crutches and the injured leg move together, followed by the uninjured leg. The stronger leg does not move first.
C.   The client should not lean on the axillary crutch pads as it can cause nerve damage. Body weight should be supported through the hands and arms.
D.   When going up stairs, the uninjured leg should move first, followed by the crutches and the affected leg.

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Correct Answer is D

Explanation

A. Maternal hypoglycemia typically does not cause fetal bradycardia.
B. Chorioamnionitis could lead to fetal tachycardia, not bradycardia.
C. Maternal fever may cause fetal tachycardia, not bradycardia.
D. Fetal anemia can lead to fetal bradycardia as the fetus struggles to maintain adequate oxygenation.

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

Correct Answer is D

Explanation

A. Recommending clients for discharge may be premature and disrupt ongoing care, potentially worsening the situation if those clients require immediate care.
B. While determining the medical needs of incoming clients through the emergency department is important, the immediate priority is ensuring sufficient staffing for the current medical needs.
C. Acting as a liaison between the facility and the media is an important role, but it is not the nurse's primary responsibility during a mass casualty event. The nurse should focus on direct patient care.
D. Calling in additional nursing staff ensures the facility has adequate personnel to care for the incoming patients, especially given the likely influx of critically ill or injured clients.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

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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Explanation

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