A nurse is teaching a client who has left-sided weakness after a stroke on how to use a cane. What instructions should the nurse include?
Hold the cane on the right side to provide support for the weaker leg.
Advance the right leg and the cane together to support the weaker leg.
Remove the rubber tip when using the cane.
Place the cane approximately 61 cm (24 inches) in front of her foot before advancing.
The Correct Answer is A
Choice A reason: Holding the cane on the opposite side of the weaker leg is the correct technique. For a client with left-sided weakness, holding the cane on the right side provides better support and balance. This method helps distribute weight away from the weaker side and reduces the risk of falls. The cane should be moved simultaneously with the weaker leg to maintain stability.
Choice B reason: Advancing the right leg and the cane together is incorrect. The correct technique involves moving the cane and the weaker leg (left leg in this case) together. This coordination helps in maintaining balance and provides the necessary support to the weaker side. Moving the stronger leg and the cane together does not offer the same level of support.
Choice C reason: Removing the rubber tip when using the cane is not advisable. The rubber tip provides traction and prevents the cane from slipping on various surfaces. Removing it would increase the risk of falls and injuries. The rubber tip is an essential safety feature of the cane.
Choice D reason: Placing the cane approximately 61 cm (24 inches) in front of the foot is too far. The cane should be placed about 15-20 cm (6-8 inches) in front of the foot to ensure stability and ease of movement. Placing the cane too far ahead can cause instability and make walking more difficult.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.
Choice B Reason:
The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.
Choice C Reason:
The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.
Choice D Reason:
The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.
Correct Answer is A
Explanation
Choice A Reason:
“N95 (personal respirator mask)” is correct because varicella (chickenpox) is an airborne disease. The N95 mask is designed to filter out at least 95% of airborne particles, making it essential for protecting healthcare workers from inhaling infectious agents.
Choice B Reason:
“Surgical mask” is incorrect because while surgical masks provide a barrier against large respiratory droplets, they do not offer sufficient protection against airborne particles. Varicella can be transmitted through tiny airborne droplets, which necessitates the use of an N95 mask.
Choice C Reason:
“They don’t need a mask” is incorrect because healthcare workers must wear appropriate personal protective equipment (PPE) to prevent the spread of infectious diseases. Not wearing a mask would put the nurse at risk of contracting varicella.
Choice D Reason:
“Only the client needs a mask” is incorrect because while it is important for the client to wear a mask to reduce the spread of infectious droplets, the nurse also needs to wear an N95 mask to protect themselves from airborne transmission.
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