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 C
Explanation
This is because a normal FHR baseline is between 110 and 160 bpm, and anything above or below this range indicates fetal distress and should be reported to the provider. An FHR baseline of 170/min could indicate fetal tachycardia, which could be caused by maternal fever, infection, dehydration, fetal anemia, or fetal hypoxia.
Choice A is wrong because early decelerations in the FHR are normal and benign, and indicate head compression during contractions.
They do not require any intervention or reporting.
Choice B is wrong because contractions lasting 80 seconds are within the normal range for active labor, which is 40 to 90 seconds per contraction.
They do not indicate any complication or abnormality.
Choice D is wrong because a temperature of 37.4° C (99.3° F) is slightly elevated but not considered a fever. A fever is defined as a temperature of 38° C (100.4° F) or higher.
A mild increase in temperature could be due to dehydration, exertion, or environmental factors, and does not necessarily indicate infection or inflammation.
Correct Answer is D
Explanation
Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. It is more difficult to detect in people who have dark skin, so the nurse should look for cyanosis in areas where the skin is thinner and the blood supply is richer, such as the palms of the hands, the lips, the gums, and around the eyes.
These areas are less affected by melanin, the pigment that gives skin its color.
Choice A is wrong because an area of trauma may have bruising or inflammation that can mask cyanosis.
Choice B is wrong because the sacrum is not a good site to assess for cyanosis in any skin tone, as it is prone to pressure ulcers and poor circulation.
Choice C is wrong because the shoulders are not a mucous membrane and may have more melanin than other areas of the body.
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