The practical nurse (PN) is assigned to care for an older male client who is recovering from a stroke. When assisting this client to ambulate with the use of a cane, where should the PN place the cane in relation to the client's body?
On the same side as the affected extremity.
Approximately one foot away from the body to stabilize balance.
On the opposite side of the affected extremity.
In front of the body to lean on while stepping forward.
The Correct Answer is C
A. On the same side as the affected extremity: Placing the cane on the affected side reduces stability because the weaker side does not provide sufficient support. This increases the risk of falls and improper gait.
B. Approximately one foot away from the body to stabilize balance: Holding the cane too far from the body can compromise balance and coordination. Proper cane placement should maintain stability close to the body while allowing natural movement.
C. On the opposite side of the affected extremity: The cane should be held on the side opposite the weaker or affected limb. This provides optimal support and balance during ambulation, allowing the client to bear weight safely while stepping forward with the affected leg.
D. In front of the body to lean on while stepping forward: Leaning on the cane excessively shifts weight forward and can destabilize the client. The cane is intended to provide lateral support rather than function as a crutch for leaning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respiratory obstruction: Airway patency is the highest priority in the immediate postoperative period because anesthetics, sedation, or secretions can cause airway blockage. Without prompt intervention, this can quickly lead to hypoxia, respiratory arrest, and death, making it the most urgent concern.
B. Infection: Although infection prevention is critical, it is not an immediate threat in the postoperative phase. Signs of infection typically develop hours to days later, after initial recovery from anesthesia.
C. Cardiac arrest: While life-threatening, cardiac arrest is often a result of unresolved respiratory compromise. Prioritizing airway management can prevent hypoxia-induced cardiac complications.
D. Dehydration: Fluid balance is important but not an immediate threat compared to airway obstruction. Dehydration develops gradually, allowing time for assessment and correction once the client’s airway and breathing are stabilized.
Correct Answer is C
Explanation
A. Assess skin appearance and elasticity: This assessment helps evaluate hydration status but does not directly relate to the foul-smelling, cloudy urine, which may indicate a urinary tract infection (UTI).
B. Observe the feet and legs for swelling: Peripheral edema is more related to fluid retention or kidney dysfunction, but the immediate concern with cloudy, foul-smelling urine is potential infection, not edema.
C. Ask the client about urinary frequency: Changes in urinary frequency, urgency, or discomfort are key symptoms of a UTI. Gathering this information helps identify the extent of the urinary problem and guides further intervention.
D. Palpate the bladder area for distention: Bladder palpation assesses retention, which is useful in some urinary issues, but it does not directly evaluate infection or correlate with foul-smelling, cloudy urine.
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