A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
The client moves the cane 2 feet ahead.
The client holds the cane with their right hand.
The client takes a step with their left foot first.
The client advances the weaker (left) leg forward to the cane.
The Correct Answer is D
Choice A reason: Moving the cane 2 feet ahead is too far and can cause imbalance or a fall. The cane should be moved a short distance ahead, about the length of one natural step.
Choice B reason: Holding the cane with the right hand is correct for someone with left-sided weakness. The cane should be used on the stronger side of the body to provide support for the weaker side.
Choice C reason : Taking a step with the left foot first is not correct because the weaker leg should be advanced to the cane to ensure stability and support when moving.
Choice D reason: Advancing the weaker leg forward to the cane is correct. The cane provides support for the weaker leg, helping to maintain balance as the client walks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Changing the ostomy pouch daily is not necessary and could lead to skin irritation from the frequent removal and application of the adhesive. Ostomy pouches are designed to be worn for several days, and the schedule for changing them can vary based on the type of pouch and individual needs.
Choice B reason: Emptying the ostomy pouch when it is 2/3 full is the correct instruction. This prevents the pouch from becoming too heavy, which could pull on the stoma and cause discomfort or damage. It also reduces the risk of leaks and odors.
Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be trimmed to match the size of the stoma to provide a secure fit and prevent leakage of the contents onto the skin, which could cause irritation or infection.
Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not recommended. Lotions or creams can interfere with the adhesive of the ostomy appliance and reduce the effectiveness of the seal. The peristomal skin should be clean and dry to ensure the best adherence of the ostomy appliance.
Correct Answer is A
Explanation
Choice A reason: Asking if the client feels like they have food stuck at the base of their throat is a pertinent question for assessing swallowing in a client with oral achalasia. Achalasia is characterized by difficulty in swallowing due to the inability of the lower esophageal sphincter to relax, leading to a sensation of food being stuck.
Choice B reason: While burning sensations in the throat can be associated with gastroesophageal reflux disease (GERD), they are not specific to achalasia. However, some clients with achalasia may experience similar symptoms due to food stasis and fermentation in the esophagus.
Choice C reason: Feelings of fullness in the neck are not a typical symptom of achalasia. Achalasia primarily affects the esophagus and does not usually cause a sensation of fullness in the neck.
Choice D reason: Pain while swallowing, or odynophagia, can occur in achalasia but is more commonly associated with conditions that cause inflammation or irritation of the esophagus, such as infections or ingestion of irritants.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today