A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?

"Advance the cane 12 inches forward when walking."

"Hold the cane on the side of your affected leg when walking."

"Keep the cane at the same level as the affected leg when climbing stairs."

"Move your unaffected leg before your affected leg when walking."

Answer and Explanation

The Correct Answer is D

A.   Advancing the cane 12 inches forward when walking is not a standard instruction for cane use. Typically, the cane is advanced a short distance ahead of the individual's affected leg to provide support and stability during ambulation.
B.   Holding the cane on the side of the affected leg does not provide adequate support and stability to the affected side while walking.
C.   When climbing stairs, the cane should be held in the hand opposite the affected leg to provide support and balance. Placing the cane at the same level as the affected leg may
lead to imbalance and difficulty ascending stairs safely.

D. This is because when using a cane for ambulation, the cane should be held on the stronger side of the body, and the user should move the cane forward simultaneously with the affected (weaker) leg. Then, the stronger leg is moved forward, which helps in maintaining balance and stability during walking.

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Correct Answer is A

Explanation

A. Deep vein thrombosis (DVT) is a condition characterized by the formation of blood clots in deep veins, commonly occurring in the lower extremities. DVT can be acquired during hospitalization due to factors such as immobility, surgery, or certain medical treatments.
B. Hypothyroidism, diabetes mellitus, and hypertension are chronic medical

conditions that may be managed or exacerbated during hospitalization but are not typically considered hospital-acquired injuries. They are often present before
hospitalization and may require ongoing management during the hospital stay.

C. Diabetes mellitus is a chronic condition characterized by elevated blood sugar levels due to either insufficient insulin production or the body's inability to use
insulin effectively. While diabetes management may be necessary during

hospitalization, it is not considered a hospital-acquired injury. Instead, it is a pre- existing condition that requires ongoing monitoring and treatment.

D. Hypertension, or high blood pressure, is a chronic condition that may require management during hospitalization but is not typically considered a hospital- acquired injury. Hypertension is often managed with medications and lifestyle modifications and may be monitored and treated during the hospital stay.

A. Standing close to the patient B. Twisting at the torso C. Maintaining a wide base of support D. Using proper body mechanics

Correct Answer is B

Explanation

A. Standing close to the patient is a recommended practice to maintain proximity and control during patient transfers. This action is appropriate and does not require
intervention.
B. Twisting at the torso can lead to strain or injury to the nurse's back. It is essential to avoid twisting while performing patient transfers to maintain proper body mechanics and prevent injury.
C. Maintaining a wide base of support is important for stability and balance during patient transfers. This action is appropriate and promotes safe transfer techniques.
D. Using proper body mechanics is crucial for preventing injury during patient transfers.

However, the specific concern in this scenario is twisting at the torso, which can lead to strain or injury, rather than overall body mechanics.

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A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?

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