A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?

Four-point alternating gait

Swing-through gait

Three-point gait

Two-point alternating gait

Answer and Explanation

The Correct Answer is C

A. Four-point alternating gait:

This gait involves a more natural and stable walking pattern. However, it requires weight-bearing on both legs, which may not be suitable for a client who can only bear weight on one leg.

B. Swing-through gait:

The swing-through gait is typically used by clients with bilateral lower extremity weakness. It involves swinging both legs through while supporting weight on the crutches. This gait is not suitable for a client who can only bear weight on one leg.

C. Three-point gait:

This gait is appropriate for a client who can only bear weight on one leg. In a three-point gait, the client uses crutches and swings or hops the non-weight-bearing leg forward, landing on the good leg. This gait provides stability and reduces weight-bearing on the affected leg.

D. Two-point alternating gait:

In a two-point alternating gait, the client advances the crutch and the opposite foot simultaneously. This gait is more energy-efficient than the four-point gait but requires weight-bearing on both legs. It is not suitable for a client who can only bear weight on one leg.

Diagram of different axillary crutch walking. | Download Scientific Diagram

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Correct Answer is A

Explanation

A. Ask the family if they wish to assist in washing the client's body:

This is an appropriate action. Providing an opportunity for the family to participate in postmortem care can be a culturally sensitive and therapeutic approach. It allows the family to be involved in a meaningful way and may contribute to the grieving process.

B. Turn overhead lights to a bright setting:

This is incorrect. The environment for postmortem care should be handled with respect and consideration for the family. Turning the lights to a bright setting may create an uncomfortable or clinical atmosphere. A calm and serene environment is more appropriate for this sensitive task.

C. Leave the client's eyes open until the family views the body:

This is incorrect. It is customary to gently close the deceased person's eyes as part of postmortem care. Leaving the eyes open may be distressing for the family and does not contribute to creating a peaceful appearance.

D. Remove the client's dentures for their family to keep:

This is incorrect. Dentures are typically returned to the family rather than kept by the family. The nurse should handle the removal of any personal items with sensitivity and respect, returning them to the family as appropriate.

A. Ensure the client's heels are not touching the mattress. B. Massage the client's bony prominences. C. Raise the head of the client's bed to a 60° angle. D. Reposition the client every 4 hr.

Correct Answer is A

Explanation

A.Ensuring the client's heels are not touching the mattress: Pressure injuries, particularly on the heels, are common in clients who are immobile and on bed rest. Elevating the heels off the mattress helps to alleviate pressure and reduce the risk of developing pressure injuries in this area.

B.Massaging the client's bony prominences: Massage can increase the risk of tissue damage and is not recommended as a preventive measure for pressure injuries.

C.Raising the head of the client's bed to a 60° angle: While elevation may be beneficial for certain conditions, it is not a direct preventive measure for pressure injuries. Repositioning and pressure relief are more crucial.

D, Reposition the client every 4 hr.

Repositioning the client regularly is indeed a crucial measure to prevent pressure injuries. However, repositioning every 2 hours is typically recommended for clients at risk of developing pressure injuries, as prolonged pressure on any one area can lead to tissue damage.

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A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to provide postmortem care for a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative and is on bed rest. Which of the following actions should the nurse take to decrease the client's risk of developing a pressure injury?

Correct Answer is A

Explanation

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