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 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 not correct because in a three-point gait, the two crutches and the affected leg move together, followed by the stronger leg.
Choice B rationale:
Supporting body weight while leaning on the axillary crutch pads is incorrect as this can cause nerve damage under the arms. Weight should be supported by the hands while using crutches.
Choice C rationale:
Stepping with the affected leg first when going up stairs is incorrect. When ascending stairs, the unaffected (stronger) leg should be moved first, followed by the affected leg and crutches.
Choice D rationale:
Positioning both hands on the grips with elbows slightly flexed is correct as it allows for proper weight distribution through the arms and hands, which is essential for balance and safety while using crutches.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.
Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.
The nurse should provide a structured and consistent daily routine for the client.
Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.
The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.
Correct Answer is ["B","C","D"]
Explanation
B, C, and D. These findings require follow-up because they indicate possible complications of chemotherapy, such as infection, low blood cell counts, and lung damage.
Choice B is correct because a temperature of 38.6° C (101.5° F) is a sign of fever, which can indicate an infection. Chemotherapy can weaken the immune system and make the client more prone to infections.
Choice C is correct because a WBC count of 3,800/mm3 is below the normal range of 5,000 to 10,000/mm3 and indicates leukopenia, a condition of low white blood cells. Chemotherapy can cause leukopenia by damaging the bone marrow where blood cells are produced.
Choice D is correct because crackles heard at the bases of the lungs are abnormal breath sounds that can indicate fluid accumulation or inflammation in the lungs. Chemotherapy can cause lung damage by affecting the cells that line the airways or by triggering an immune response.
Choice A is wrong because a potassium level of 3.6 mEq/L is within the normal range of 3.5 to 5 mEq/L and does not require follow-up.
Choice E is wrong because a blood pressure of 114/56 mm Hg is within the normal range of less than 120/80 mm Hg and does not require follow-up.
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