A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer.
The employer asks the nurse about the client's condition.
Which of the following is an appropriate response by the nurse?

Choice A rationale

Standing with the crutch tips against the feet is incorrect. Proper crutch placement involves positioning the crutches slightly forward and to the side of the feet to provide stability and prevent tripping.

Choice B rationale

Bearing weight on the unaffected leg is the correct instruction for using the three-point gait. This technique allows the client to move the crutches and the affected leg together while bearing weight on the unaffected leg, promoting balance and mobility.

Choice C rationale

Keeping the crutches at the level of the axillae is incorrect. Crutches should be positioned with a 1-2 inch gap below the axillae to prevent nerve damage and ensure proper support.

Choice D rationale

Holding the arms straight when walking is incorrect. The elbows should be slightly bent to allow for comfortable movement and better control of the crutches.

Choice A rationale

A client who receives burns from a heating pad has experienced harm due to the healthcare setting or treatment. An incident report should be completed to document the injury and investigate the cause to prevent future occurrences.

Choice B rationale

A client's dissatisfaction with meal temperature does not typically require an incident report unless it leads to significant issues such as foodborne illness or other adverse effects. It is usually managed through the facility's complaint process.

Choice C rationale

If a client becomes disoriented and falls out of bed, it is crucial to complete an incident report to document the event, assess the cause, and implement measures to prevent similar incidents. This helps ensure client safety and continuous quality improvement.

Choice D rationale

When a client's visitor becomes dizzy and faints in the client's room, an incident report should be completed to document the occurrence and initiate an investigation into the cause. This helps in providing appropriate care and preventing future incidents.

Choice E rationale

A client's inability to afford recommended physical therapy is an important issue but does not typically require an incident report. This situation should be addressed through social services or financial counseling to find a solution.