The practical nurse (PN) plans to reinforce the proper use of a cane to an older client who is recovering from a stroke. When providing information to the client how to correctly use this assistive device, where should the PN reinforce with the client to place the cane?

On the unaffected side.

In front of the body to provide support while stepping forward.

Approximately one foot away from the body to stabilize balance.

On the affected side.

Answer and Explanation

The Correct Answer is A

A. On the unaffected side: A cane should be held on the stronger, unaffected side to provide optimal support and stability. Placing it on the unaffected side allows the client to bear weight safely while reducing stress on the weaker, affected side during ambulation.

B. In front of the body to provide support while stepping forward: While the cane moves forward simultaneously with the opposite leg, holding it directly in front does not maximize lateral support. Correct placement beside the unaffected leg ensures balance and coordinated gait.

C. Approximately one foot away from the body to stabilize balance: Positioning the cane too far from the body can reduce stability and increase the risk of falls. Proper placement should be close enough to support weight without overreaching or causing imbalance.

D. On the affected side: Holding the cane on the weaker, affected side does not provide adequate support and may increase the risk of falls. The cane functions as a stabilizing aid, which is most effective on the stronger side.

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Correct Answer is A

Explanation

A. Sitting on side of bed with feet flat on the floor: Sitting upright with feet supported allows maximum lung expansion and diaphragmatic movement, facilitating effective deep breathing and coughing. This position also promotes airway clearance and reduces the risk of postoperative complications like atelectasis.

B. Left-lateral with pillow between flexed knees: Lateral positioning may be comfortable for rest but does not optimize lung expansion or coughing efficiency. It can limit diaphragmatic movement and the force generated during a cough.

C. Lying prone with the head turned to one side: The prone position restricts lung expansion and is uncomfortable for many postoperative clients. It is not conducive to effective coughing or deep breathing exercises.

D. Leaning forward over the bedside table: While this position may slightly assist in coughing, it does not provide as stable or effective support for diaphragmatic movement as sitting upright with feet flat, which promotes maximal lung expansion.

A. Slide hands under the client's lumbar area and knees. B. Turn the client away from the PN using a turning sheet. C. Put the bed rails up on the opposite side of the bed. D. Grasp the client's hand to pull the client towards the PN.

Correct Answer is B

Explanation

A. Slide hands under the client's lumbar area and knees: Manually lifting or sliding a client without a mechanical aid increases the risk of injury to both the client and the nurse. This method does not provide adequate support or leverage for safe turning.

B. Turn the client away from the PN using a turning sheet: Using a turning sheet allows for safe, controlled movement of a dependent client while reducing strain on the nurse. It also minimizes the risk of skin shearing or musculoskeletal injury, ensuring client safety during repositioning.

C. Put the bed rails up on the opposite side of the bed: Raising bed rails may prevent falls but does not assist in the actual turning process. It does not address the immediate need for safe and controlled movement of the client.

D. Grasp the client's hand to pull the client towards the PN: Pulling on the client’s arm can cause joint injury, pain, or skin tears. It does not provide adequate support for turning a dependent client safely.

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The practical nurse (PN) plans to reinforce the proper use of a cane to an older client who is recovering from a stroke. When providing information to the client how to correctly use this assistive device, where should the PN reinforce with the client to place the cane?

Nursing Test Bank

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