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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A reason: Dehydration. Dehydration can cause dark, concentrated urine but does not typically cause blood-tinged urine. Blood-tinged urine usually indicates a problem within the urinary system itself, making dehydration an unlikely cause.
B reason: Pernicious anemia. Pernicious anemia is a condition related to a deficiency in vitamin B12 and affects red blood cell production. It does not typically cause blood in the urine, making it an unlikely explanation for blood-tinged urine in the catheter bag.
C reason: Prostate enlargement. Prostate enlargement, or benign prostatic hyperplasia (BPH), can cause urinary symptoms such as difficulty urinating or frequent urination. However, it is less likely to cause blood-tinged urine directly. While it may lead to other complications, it is not the most direct cause of this symptom.
D reason: Bladder infection. Bladder infection, or cystitis, can cause blood-tinged urine as a result of inflammation and irritation of the bladder lining. This is a common symptom of urinary tract infections (UTIs), making it the most likely cause of the observed symptom in this scenario.
Correct Answer is D
Explanation
A reason:
Using lotion on irritated skin before applying a new patch is incorrect. Lotion can interfere with the adhesion and absorption of the medication from the patch. It's important to keep the skin clean and dry.
B reason:
Removing the old patch and applying a new one in the same location is not recommended. The skin needs time to recover from the adhesive and medication exposure. Patches should be rotated to different areas to prevent skin irritation.
C reason:
Pressing the patch securely in place is important, but the statement is incomplete without mentioning the need to clean and dry the area first. Proper skin preparation is crucial for effective patch adhesion.
D reason:
Cleaning and drying the area before applying the patch is correct. This ensures that the patch adheres properly and that the medication is effectively absorbed through the skin.
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