A nurse is teaching 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."
"Keep the cane at the same level as the affected leg when climbing stairs."
"Hold the cane on the side of your affected leg when walking."
"Move your unaffected leg before your affected leg when walking."
The Correct Answer is D
A. "Advance the cane 12 inches forward when walking." Advancing the cane 12 inches forward is not practical; the cane should be moved in a manner that aligns with the client's steps for better balance and support. The movement of the cane should be synchronized with the client's stride rather than a fixed distance.
B. "Keep the cane at the same level as the affected leg when climbing stairs." When climbing stairs, the cane should be held on the side of the unaffected leg to provide optimal support and balance. Keeping the cane level with the affected leg is incorrect and does not provide adequate support.
C. "Hold the cane on the side of your affected leg when walking." The cane should be held on the side opposite the affected leg to provide better stability and support. Holding the cane on the affected side would not offer the necessary support for effective ambulation.
D. "Move your unaffected leg before your affected leg when walking." This is the correct technique as it ensures better balance and stability. Moving the unaffected leg first while using the cane allows for a more secure and coordinated gait, reducing the risk of falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Droplet: Incorrect. Droplet precautions are used for infections spread through respiratory droplets, such as influenza or meningitis, not for immunocompromised clients undergoing stem-cell transplants.
B. Protective: Correct. Protective precautions, also known as neutropenic precautions or reverse isolation, are necessary for clients who are immunocompromised, such as those who have had a stem-cell transplant. These precautions include using barrier protection to prevent infection due to the client's weakened immune system.
C. Contact: Incorrect. Contact precautions are used for infections spread by direct or indirect contact with contaminated surfaces or items, such as Clostridium difficile, not for immunocompromised patients.
D. Airborne: Incorrect. Airborne precautions are used for infections that spread through the air over long distances, such as tuberculosis or measles, and are not specifically needed for clients with compromised immunity post-transplant.
Correct Answer is D
Explanation
A. Anemia: While stress can have various effects on the body, anemia is not specifically a direct manifestation of prolonged stress. It is more commonly associated with nutritional deficiencies or chronic disease.
B. Hypoglycemia: Prolonged stress typically leads to increased levels of cortisol and other stress hormones, which can cause hyperglycemia (elevated blood sugar) rather than hypoglycemia (low blood sugar).
C. Decreased blood pressure: Prolonged stress usually causes increased blood pressure rather than decreased blood pressure. The body's stress response involves the release of hormones that typically raise blood pressure.
D. Impaired immune function: Prolonged stress can lead to immune system suppression, making the body more susceptible to infections and illnesses. This is a well-documented effect of chronic stress and is thus a correct manifestation to include in the teaching.
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