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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer an antiemetic:
Administering an antiemetic might be necessary to relieve nausea and vomiting, but it is not the first action. Before administering medications, it is essential to assess the client's condition and gather information about the underlying cause of the symptoms.
B. Offer pain medication:
Offering pain medication is not the first action. The nurse needs to assess the client's condition, determine the cause of the pain, and gather more information before administering pain relief. Administering pain medication before a thorough assessment can mask important clinical signs and symptoms.
C. Palpate the abdomen:
Palpating the abdomen is an important step in the assessment, but it should follow auscultation of bowel sounds. Palpation can be deferred if there is concern about possible inflammation (as in suspected appendicitis) to avoid causing further irritation.
D. Auscultate bowel sounds:
This is the correct action. Auscultating bowel sounds is the first step in assessing the gastrointestinal (GI) function. The reported symptoms of right lower quadrant pain, nausea, and vomiting could be indicative of various GI issues, such as appendicitis. Assessing bowel sounds helps the nurse gather information about the status of peristalsis and potential obstructions.
Correct Answer is ["A","B","C","F"]
Explanation
A.Swollen tongue: Swelling of the tongue can indicate an allergic reaction, which could progress to a severe condition known as anaphylaxis. Immediate intervention is necessary.
B. Heart rate: While the heart rate is not directly mentioned in the notes, an increase in heart rate could be a physiological response to an allergic reaction or anaphylaxis. Monitoring heart rate is crucial in assessing the severity of the reaction.
C. Bilateral breath sounds with scattered wheezing upon auscultation: Wheezing indicates a potential respiratory issue, and when associated with itching, urticaria, and swelling, it suggests an allergic reaction or anaphylaxis. Prompt intervention is needed.
D. Blood pressure: Although blood pressure is important to monitor, it is not directly mentioned in the nurses' notes. However, if anaphylaxis or a severe allergic reaction is suspected, blood pressure can be affected, and it should be monitored.
E. Temperature: Fever is not mentioned in the notes, and the information provided suggests an immediate allergic reaction rather than an infectious process. Monitoring temperature is generally important but may not be a priority in this specific context.
F.Urticaria (hives): Hives are a sign of an allergic reaction and, when accompanied by other symptoms like swelling, require immediate attention.
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