A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?
A client who is able to bear full weight on both lower extremities.
A client who has bilateral knee replacements with partial weight bearing on both legs.
A client who has a right femur fracture with no weight bearing on the affected leg.
A client who has bilateral leg braces due to paralysis of the lower extremities.
The Correct Answer is C
A reason: A client who is able to bear full weight on both lower extremities. A client who can bear full weight on both lower extremities does not need to use a three-point gait. This gait is designed for individuals who cannot bear weight on one leg, making this choice incorrect for the given scenario.
B reason: A client who has bilateral knee replacements with partial weight bearing on both legs. A client with bilateral knee replacements and partial weight bearing needs a different type of gait that distributes weight evenly across both legs. The three-point gait is not suitable for this condition, thus making this choice inappropriate.
C reason: A client who has a right femur fracture with no weight bearing on the affected leg. A three-point gait is specifically used for individuals who are unable to bear weight on one leg. This gait involves using crutches and the unaffected leg to form a tripod, which provides stability while moving. Therefore, this option is the correct choice.
D reason: A client who has bilateral leg braces due to paralysis of the lower extremities. A client with bilateral leg braces due to paralysis would require a different gait pattern that accommodates the use of braces and supports for both legs. The three-point gait is not designed for bilateral leg paralysis, making this choice incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["740"]
Explanation
To convert the fluid intake to mL:
- 4 oz juice = 120 mL
- 6 oz tea = 180 mL
- Ice chips melt to half their volume = 50 mL
- IV bolus = 150 mL
- 8 oz broth = 240 mL
Adding these values gives: 120 + 180 + 50 + 150 + 240 = 740 mL
Therefore, the nurse should record a total intake of 740 mL.
Correct Answer is C
Explanation
A reason:
Applying a heat lamp twice a day is incorrect. Heat lamps can increase the risk of burns and do not have a proven benefit in the treatment of pressure ulcers.
B reason:
Massaging reddened areas is incorrect. Massaging areas of redness can cause further tissue damage, especially in areas that are already compromised.
C reason:
Repositioning the client at least every 2 hours is correct. This helps to relieve pressure on the ulcer and promote circulation, which are crucial for the healing process.
D reason:
Cleaning the wound with hydrogen peroxide solution is incorrect. Hydrogen peroxide can damage healthy tissue and delay wound healing. Saline or other appropriate wound cleansers should be used instead.
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