What is the purpose of instructing the client to move the walker forward 6 to 8 inches, setting it down with all four feet on the floor when ambulating?

To avoid putting pressure on the client's stronger leg

To ensure proper positioning of the hands on the walker

To provide support for the client's weight while moving their weaker leg

To maintain the client's center of gravity close to the body

Answer and Explanation

The Correct Answer is C

A.   The goal is not to avoid pressure on the stronger leg; rather, the walker is used to assist with balance and support for both legs. The client typically puts weight on both legs when using the walker, especially when moving it forward.
B.   While proper hand positioning is important for stability, the specific instruction to move the walker forward 6 to 8 inches is primarily focused on facilitating safe movement and balance, rather than just ensuring hand positioning. Therefore, this is not the main purpose.
C.   Moving the walker forward provides a stable base of support before the client steps forward with their weaker leg. This technique allows the client to safely shift their weight onto the walker, minimizing the risk of falls and ensuring adequate support during ambulation.
D.   While maintaining the center of gravity is important for balance, the specific instruction to move the walker forward 6 to 8 inches is primarily about creating a safe distance to support the client’s weight. This action does help with balance, but it’s not the primary reason for that specific movement.

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Correct Answer is C

Explanation

A. Using hot water is not recommended as it can cause skin irritation or burns, especially in vulnerable populations such as those with urinary incontinence. Warm or lukewarm water is more appropriate for cleaning sensitive skin.
B. Applying cornstarch can sometimes be used to absorb moisture and reduce friction; however, it is not the first-line recommendation. It may also promote yeast growth in the presence of moisture, so it should be used with caution.
C. Using a pH-balanced cleanser helps maintain the natural acidity of the skin, which is important for skin integrity and preventing irritation. This type of cleanser is less likely to disrupt the skin's barrier, reducing the risk of skin breakdown and infection.
D. While air-drying can be beneficial in some cases, it is generally not the best practice after cleaning. Gently patting the skin dry with a soft towel is usually recommended to avoid irritation. Allowing skin to remain damp can increase the risk of skin breakdown.

A. The client rates their pain as an 8 on a scale of 0 to 10. B. The client reports a burning sensation. C. The client grimaces when they move. D. The client states the pain is located on their abdomen.

Correct Answer is C

Explanation

A. This is a subjective indicator of pain. The pain rating is based on the client’s personal experience and perception of their pain intensity. It reflects the individual’s feelings rather than observable data.
B. This statement is also subjective. Describing pain as a "burning sensation" comes from the client's personal experience and interpretation of their symptoms, which cannot be measured or observed by others.
C. This is an objective indicator of pain. A grimace is an observable behavior that can indicate discomfort or pain. It is something that the nurse can see and assess, making it an objective finding.
D. This is another subjective indicator. While knowing the location of pain is important for diagnosis and treatment, the statement reflects the client’s personal experience of pain and cannot be measured or observed directly.

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What is the purpose of instructing the client to move the walker forward 6 to 8 inches, setting it down with all four feet on the floor when ambulating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data on a client for manifestations of pain. Which of the following findings is an objective indicator of pain?

Correct Answer is C

Explanation

A nurse is caring for a client who had radiation therapy and is experiencing painful dermatitis. The nurse should identify the client is experiencing which of the following types of pain?

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A nurse is documenting in a client's health record using the problem-intervention-evaluation charting model (PIE). Which of the following information should be included in the intervention component?

A nurse is assisting with teaching a newly licensed nurse about pain. Which of the following is an example of acute pain?

Which of the following is an essential component of patient safety in healthcare settings?

A nurse is caring for a client who reports abdominal pain. The nurse asks the client to describe what the pain feels like. The nurse is using which of the following components of the PQRST mnemonic?

A nurse is assisting with teaching a newly licensed nurse about ethical principles. Which of the following is an example of autonomy?

A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?