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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

Stepping with his affected leg first when going up stairs

Positioning both hands on the grips with his elbows slightly flexed

Supporting his body weight while leaning on the axillary crutch pads

Answer and Explanation

The Correct Answer is C

The correct answer is a. Moving both crutches with the stronger leg forward first.

Rationale for Choice C:

Proper positioning of the hands on the grips and keeping the elbows slightly flexed helps ensure stability and control while using the crutches.

Rationale for Other Choices:

a. In a three-point gait, the client moves both crutches and the affected leg together, followed by the unaffected leg. The stronger leg does not move forward first.

b. Stepping with the affected leg first when going up stairs: This action is incorrect for the three-point gait. When ascending stairs, the client should move the stronger leg up first, followed by the crutches and the affected leg.

d. Supporting his body weight while leaning on the axillary crutch pads: This action is also correct for general crutch use, but it does not specifically address the weight-bearing restrictions and movement pattern of the three-point gait.

Additional Information:

Practice and supervision: It's essential for the client to practice the three-point gait under the supervision of a healthcare professional to ensure proper technique and safety.
Gradual progression: The client should gradually increase their distance and duration of crutch use as their strength and coordination improve.
Pain management: Adequate pain management is crucial to allow the client to participate in rehabilitation and regain mobility.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Incorrect. Placing a towel roll under the client's neck is a preventive measure to maintain proper cervical alignment, but it does not specifically address contracture prevention.

B. Incorrect. This can promote flexion of the knees, which may actually contribute to knee flexion contractures over time. While it might be comfortable for the client, it's not a preventive measure against contractures.

C. Correct. Orthotics can help maintain proper alignment of the foot and ankle, preventing foot drop and other related contractures. They are designed to support joints and muscles, minimizing the risk of stiffness and contracture formation.

D. Incorrect. Aligning a trochanter wedge between the client's legs might help prevent external rotation of the hips but does not specifically address contracture prevention.

A. Confirm that the client is able to urinate. B. Check the client's serum albumin levels. C. Compare the client's current weight with preprocedure weight. D. Examine for leakage at the site of the procedure.

Correct Answer is C

Explanation

A. Incorrect. Urination is not directly related to the evaluation of the effectiveness of a paracentesis procedure.
B. Incorrect. Checking serum albumin levels may be important in managing ascites, but it is not a direct measure of the immediate effectiveness of the paracentesis.
C. Correct. Monitoring the client's weight is a common way to assess the effectiveness of a paracentesis, as the procedure aims to remove excess abdominal fluid (ascites), which can lead to a reduction in body weight.
D. Incorrect. Examining for leakage at the site of the procedure is important for safety but does not directly reflect the effectiveness of the paracentesis.

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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?

Nursing Test Bank

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Correct Answer is C

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