A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
When walking, move your left foot forward first.
Keep your elbow straight when you hold the cane.
Move the cane forward 18 inches with each step.
Hold the cane with your left hand.
The Correct Answer is A
A reason:
When walking, moving the left foot forward first is correct. For clients with left-sided weakness, the cane should be used to provide support for the weak side. Moving the left foot first while using the cane helps maintain balance and stability.
B reason:
Keeping the elbow straight when holding the cane is incorrect. The elbow should be slightly bent when holding the cane to allow for better control and shock absorption, reducing strain on the arm.
C reason:
Moving the cane forward 18 inches with each step is incorrect. The cane should be moved a comfortable distance forward, typically about 6 to 12 inches, to maintain stability and support without overreaching.
D reason:
Holding the cane with the left hand is incorrect. For left-sided weakness, the cane should be held in the right hand to provide support and balance on the opposite side of the weakness.
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Correct Answer is B
Explanation
A reason:
The cane's height should be the same as the distance from the floor to the wrist crease, not the hip bone. This ensures proper support and ergonomics while walking.
B reason:
Advancing the weak leg forward to the cane, then moving the strong leg, is correct. This method provides support and balance for the weaker leg during ambulation.
C reason:
Advancing the cane 12 to 14 inches is too far. The cane should be advanced about 6 to 10 inches to ensure stability and support.
D reason:
The cane should be held in the hand opposite the weak leg (the stronger side), not the weak hand. This helps to provide better support and balance.
Correct Answer is D
Explanation
A reason:
Holding a sterile item at just above waist level is correct practice. This helps maintain the sterility of the item by keeping it within the sterile field and preventing it from touching non-sterile surfaces.
B reason:
Placing a sterile dressing 5 cm (2 in) from the border of the sterile field is appropriate. The edges of the sterile field (usually about 2.5 cm or 1 in) are considered non-sterile, so placing items within this boundary maintains sterility.
C reason:
Opening the sterile tray by first unfolding the flap farthest from the body is correct. This technique prevents the nurse's hands and arms from passing over the sterile contents, thus maintaining the sterility of the field.
D reason:
Opening a sterile package over the middle of the sterile field is incorrect. This action can lead to contamination as the outer packaging, which is non-sterile, could contact the sterile field.
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