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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orthostatic hypotension is characterized by a drop in blood pressure upon standing,
which can lead to dizziness or lightheadedness and increase the risk of falls, especially in older adults.
B. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg
within 3 minutes of standing up.
C. Orthostatic hypotension does not directly increase the risk of a pulmonary embolism.
A pulmonary embolism is a separate medical condition involving a blockage in one of the pulmonary arteries in the lungs.
D. Orthostatic hypotension is typically indicated by a decrease in systolic blood pressure, not diastolic blood pressure.
Correct Answer is C
Explanation
A. The list of medications is typically included in the Background component of the ISBARR communication tool, as it provides important information about the client's ongoing treatment and medications.
B. Treatment plans and interventions are generally discussed in the Assessment and Recommendation components of the ISBARR communication tool, as they involve the nurse's assessment of the client's condition and the actions recommended for continued care.
C. The Situation component of the ISBARR communication tool focuses on providing a concise summary of the client's current medical condition or status, including relevant changes since the last report or significant events that occurred during the shift.
D. Vital signs may be included as part of the Background or Assessment components of the ISBARR communication tool, depending on their relevance to the client's current condition and any changes observed during the shift.
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