A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait.
Which of the following instructions should the nurse include?
Bear weight on the unaffected leg.
Keep the crutches at the level of the axillae.
Stand with the crutch tips against the feet.
Hold the arms straight when walking.
The Correct Answer is A
This gait pattern is used when one of the lower extremities is unable to fully bear weight due to fracture, amputation, joint replacement etc12 The client should advance both crutches and the affected leg as one unit, and then bring the unaffected leg forward to the crutches as the second unit
Choice B is wrong because keeping the crutches at the level of the axillae can cause nerve damage and reduce circulation.
The crutches should be positioned with 2 fingers of distance between the axilla and the axilla pad with the elbow flexed between 20-30 degrees
Choice C is wrong because standing with the crutch tips against the feet can cause instability and increase the risk of falling.
The crutch tips should be placed about 15 cm (6 inches) in front of and 15 cm to the side of each foot
Choice D is wrong because holding the arms straight when walking can cause fatigue and strain on the shoulders and wrists.
The client should keep a slight bend in the elbows when walking with crutches
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because a frayed electrical cord can pose a serious risk of electric shock or fire to the client and the nurse.
The nurse should act quickly to eliminate the hazard and ensure the safety of the client and others.
Choice B is wrong because accessing the facility’s maintenance protocol is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before following any protocol.
Choice C is wrong because reporting defective equipment is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before reporting it to the appropriate authority.
Choice D is wrong because requesting a replacement device is not the first action the nurse should take.
The nurse should prioritize removing the device from the room before requesting a new one.
Correct Answer is C
Explanation
The correct answer is choice C. “I will assist you in any way I can during this process.” This response shows sensitivity and respect for the client’s family and their cultural or religious beliefs. Postmortem care involves caring for a deceased patient’s body with dignity and in a manner that is consistent with the patient’s and family’s wishes.The nurse should offer to assist the family in performing the postmortem care if they request to do so.
Choice A is wrong because the family does not need to sign a release form to perform the postmortem care themselves.
There is no legal requirement for this.
Choice B is wrong because a licensed health care worker does not have to perform postmortem care.
The family can perform the care themselves if they wish, with or without the assistance of a health care worker.
Choice D is wrong because postmortem care takes place before the client leaves the facility, not after.
Postmortem care should be provided as soon as possible to prevent tissue damage or disfigurement.
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