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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A reason:
Decreasing the temperature in the client's room is incorrect. The client is already hypothermic and needs to be warmed, not further cooled.
B reason:
Requesting a prescription for an antipyretic medication is inappropriate. Antipyretics are used to lower fever, not to treat hypothermia.
C reason:
Placing a cooling fan near the client is incorrect and would exacerbate hypothermia.
D reason:
Placing a warming blanket over the client is correct. This action helps to gradually raise the client's body temperature to a safe level.
Correct Answer is B
Explanation
A reason:
Partial-thickness skin loss is characteristic of stage 2 pressure ulcers, not stage 3. Stage 2 ulcers involve damage to the epidermis and part of the dermis but do not extend deeper into the subcutaneous tissue.
B reason:
Necrotic subcutaneous tissue is a hallmark of stage 3 pressure ulcers. At this stage, the ulcer extends through the full thickness of the skin and into the subcutaneous tissue, which may become necrotic. However, it does not involve bone, tendon, or muscle exposure.
C reason:
Exposed bone is indicative of a stage 4 pressure ulcer, which is the most severe stage. Stage 4 ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, indicating deeper and more severe damage than a stage 3 ulcer.
D reason:
Blood-filled blisters are typically associated with deep tissue injury rather than stage 3 pressure ulcers. These blisters signal underlying tissue damage from sustained pressure, but they are not specific to stage 3.
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