Review the electronic health record. The nurse is preparing the client for discharge. After the nurse provides education about the use of a cane, which statement by the client indicates understanding?
“I will use the cane to support all of my weight when walking."
"I will make sure my elbow is bent slightly when I hold the cane."
"I will move the strong leg up the stairs first, then the cane, and then the weak leg."
“I will hold the cane on the weak side of my body to support it."
The Correct Answer is B
A. “I will use the cane to support all of my weight when walking.": A cane is meant to provide partial support and improve balance, not bear the client’s full weight. Relying entirely on the cane can cause instability and increase the risk of falls.
B. "I will make sure my elbow is bent slightly when I hold the cane.": Proper cane use requires a slight elbow flexion of about 20–30 degrees. This position ensures optimal support, reduces strain on the shoulder and wrist, and promotes safe ambulation.
C. "I will move the strong leg up the stairs first, then the cane, and then the weak leg.": When using a cane, it should move simultaneously with the weaker leg while ascending or descending stairs to provide support. Moving the strong leg first without coordinating the cane can compromise safety.
D. “I will hold the cane on the weak side of my body to support it.": The cane should be held on the strong side to provide counterbalance and allow the weaker leg to bear weight safely. Holding it on the weak side decreases stability and increases fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Maintain intravenous (IV) access: IV access affects line management during movement but does not determine whether the client can safely bear weight or assist with a transfer. Tubing can be secured and managed during mobility. This order does not guide the transfer method or level of assistance required.
B. No weight bearing to the right lower leg: Weight-bearing status directly determines how a transfer should be performed and whether assistive devices or additional staff are required. Ignoring this restriction can result in injury, delayed healing, or surgical complications. This order is critical for safe transfer planning.
C. Change wound dressing twice daily: Dressing frequency relates to wound management rather than mobility or transfer technique. While wounds should be protected during movement, this order does not affect how the transfer is carried out. It is not a determining factor in transfer planning.
D. Perform skin assessment every 12 hours: Routine skin assessment supports pressure injury prevention but does not influence immediate mobility decisions. This order does not dictate positioning, weight bearing, or transfer assistance needs. Transfer safety depends more on musculoskeletal and mobility restrictions.
Correct Answer is B
Explanation
A. Blood pressure: Blood pressure refers to the overall measurement of force exerted by circulating blood on the walls of arteries, typically recorded as systolic over diastolic pressure. It does not specifically describe the difference between these two values.
B. Pulse pressure: Pulse pressure is calculated as the difference between the systolic and diastolic blood pressure readings. It reflects the force generated by the heart with each contraction and provides information about arterial compliance and cardiac function.
C. Cardiac output: Cardiac output is the volume of blood the heart pumps per minute, determined by heart rate and stroke volume. It does not directly describe the numerical difference between systolic and diastolic pressures.
D. Heart rate: Heart rate is the number of heartbeats per minute and is unrelated to the difference between systolic and diastolic blood pressure. It measures cardiac rhythm, not pressure variance.
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