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.

Answer and Explanation

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 D

Explanation

A reason:

Using alcohol-based hand products after most client contact is acceptable and effective in maintaining hand hygiene, particularly when soap and water are not readily available.

B reason:

Washing hands before providing client care is a fundamental practice in infection control and is essential to prevent the spread of pathogens.

C reason:

Not wearing artificial nails when providing client care is important for infection control. Artificial nails can harbor bacteria and other pathogens, increasing the risk of transmitting infections.

D reason:

Changing gloves between clients without washing hands is incorrect and indicates a need for further teaching. Hand hygiene is necessary even when gloves are used to prevent cross-contamination. Gloves are not a substitute for proper hand washing.

A. A client who has peripheral vascular disease B. A client who has a new ankle sprain C. A client who has a spinal cord injury D. A client who is unconscious

Correct Answer is B

Explanation

A reason:

Using cold therapy for a client with peripheral vascular disease is not recommended as it can cause vasoconstriction, further impairing blood flow to already compromised extremities.

B reason:

Using cold therapy for a client with a new ankle sprain is appropriate. Cold therapy helps to reduce swelling, inflammation, and pain associated with acute injuries like sprains.

C reason:

Cold therapy for a client with a spinal cord injury is not typically indicated and may not be beneficial or could potentially cause harm, depending on the extent and location of the injury.

D reason:

Using cold therapy for a client who is unconscious requires careful consideration and is not typically indicated without a specific need. The primary concern with unconscious clients is maintaining overall care and monitoring vital signs.

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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?

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Naxlex Comprehensive Predictor Exams

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