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 ["A","D","E","F"]
Explanation
A. The client will teach back information about safe crutch walking on day 1: This goal includes a specific time frame ("on day 1") which makes it a timed component. It establishes when the client is expected to demonstrate understanding, aligning with the SMART criteria for setting time-specific goals.
B. The client will demonstrate safe crutch walking: While this goal describes a desired outcome, it does not include a time frame, so it lacks the timing component needed for SMART criteria.
C. The client will not lean on the crutches to support their body weight: This goal focuses on the behavior change but does not specify when this should be achieved, missing the timed element of SMART goals.
D. The client will ambulate 5 feet in one day: This goal has a specific time frame ("in one day"), indicating when the client should achieve the goal, which is a critical aspect of SMART outcomes.
E. The client will walk 10 feet by day 2: This goal includes a specific time frame ("by day 2"), providing a clear deadline for achieving the goal, which is essential for SMART objectives.
F. The client will walk 20 feet by day 3: This goal includes a specific time frame ("by day 3"), which provides a deadline for reaching the goal, meeting the criteria for SMART goals.
G. The client will explain 4 principles of crutch safety: This goal describes an outcome but does not include a time frame, so it lacks the timed aspect necessary for SMART goals.
H. The client will explain how to keep crutches in safe condition: This goal focuses on an outcome without specifying a deadline, thus missing the timed component required for SMART goal setting.
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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