The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

Progresses to foot touchdown and weight bearing of affected leg.

Practices bicep and triceps isometric exercises.

Inspects crutches to ensure rubber tips are intact.

Bears body weight on the palms of hands during the crutch gait.

Answer and Explanation

The Correct Answer is A

A. Progresses to foot touchdown and weight bearing of affected leg:

This choice indicates that the client understands proper crutch walking because it involves the correct progression of weight-bearing on the affected leg while using the crutches for support. In the three-point gait crutch walking technique, the client progresses by first touching down the foot of the affected leg and then transferring weight onto that leg while stepping forward with the crutches. This behavior ensures proper balance and support during ambulation.

B. Practices bicep and triceps isometric exercises:

This choice does not directly indicate understanding of proper crutch walking. While strengthening the biceps and triceps muscles can be beneficial for overall strength and endurance, it is not a specific behavior related to proper crutch walking technique.

C. Inspects crutches to ensure rubber tips are intact:

While it is important to inspect crutches regularly to ensure they are in good condition, this behavior alone does not necessarily indicate an understanding of proper crutch walking technique. It is more related to equipment maintenance and safety rather than the actual execution of crutch walking.

D. Bears body weight on the palms of hands during the crutch gait:

This choice suggests an incorrect technique. Proper crutch walking technique involves bearing weight on the hands through the hand grips of the crutches rather than the palms. Placing excessive weight on the palms can lead to discomfort, injury, and improper weight distribution, which could hinder effective ambulation.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Encourage increased fluid intake and measure urinary output every 8 hours:

While hydration and monitoring urinary output are important aspects of overall health care, they are not specifically related to managing chronic pain. Therefore, this intervention may not be directly relevant to addressing the client's pain.

B. Assist the client to ambulate as much as possible during waking hours:

Ambulation helps maintain mobility, prevent complications like muscle atrophy and deep vein thrombosis, and can improve overall well-being. For clients with chronic pain, assisting with ambulation can be beneficial in managing pain and improving quality of life. The goal is to balance activity with the client's pain tolerance and capabilities.

C. Determine client's subjective measure of pain using a numerical pain scale:

Using a numerical pain scale helps assess the intensity of pain and monitor changes over time. It provides valuable information for tailoring pain management strategies to the client's needs and allows for evaluating the effectiveness of interventions.

D. Provide comfort measures such as topical warm application and tactile massage:

Comfort measures such as warm applications and massage can help alleviate pain and promote relaxation. These interventions address the client's comfort and well-being, making them appropriate for inclusion in the plan of care for managing chronic pain.

E. Implement a 24-hour schedule of routine administration of prescribed analgesic:

Establishing a regular schedule of analgesic administration helps maintain consistent pain control and prevents breakthrough pain. This intervention is essential for managing chronic pain effectively and promoting the client's comfort and quality of life.

A. Drink a mixture of warm water, whiskey, and honey at bedtime. B. Ask the healthcare provider for a mild sedative for bedtime. C. Avoid drinking caffeinated beverages late in the day. D. Take an afternoon nap to make up for missed sleep. E. Establish a regular time for going to bed and getting up.

Correct Answer is ["C","E"]

Explanation

A. Drink a mixture of warm water, whiskey, and honey at bedtime:

This suggestion is not appropriate as alcohol consumption close to bedtime can disrupt sleep patterns and exacerbate sleep problems. Additionally, alcohol can interact with medications and pose risks to health.

B. Ask the healthcare provider for a mild sedative for bedtime:

While medication may be prescribed for sleep disturbances in some cases, it should not be the first line of treatment, especially in older adults. Sedatives can have adverse effects and may lead to dependency if used long-term. Non-pharmacological interventions should be tried first.

C. Avoid drinking caffeinated beverages late in the day:

This is an appropriate suggestion. Caffeine is a stimulant that can interfere with sleep, so avoiding caffeinated beverages late in the day can help improve sleep quality.

D. Take an afternoon nap to make up for missed sleep:

While napping may be beneficial for some individuals, particularly if they are sleep deprived, it can worsen sleep difficulties in others, especially if taken late in the day. For individuals with insomnia or frequent nighttime awakenings, avoiding naps or limiting them to earlier in the day may be helpful.

E. Establish a regular time for going to bed and getting up:

This is an appropriate suggestion. Establishing a consistent sleep schedule helps regulate the body's internal clock and promotes better sleep quality. Going to bed and waking up at the same time each day, even on weekends, can help synchronize sleep-wake cycles and improve overall sleep patterns.

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The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the admission assessment of a client with chronic pain. What Intervention(s) should the nurse Include in the client's plan of care? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

Correct Answer is ["C","E"]

Explanation

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