17-year-old male arrives at the emergency department following playing baseball. He slid into a base, felt a 'pop', and had pain in his right ankle.
The client reports pain of 7 out of 10 in his right ankle, which is described as throbbing. Right pedal pulse was 2+, and the sensation was intact.
The client had a limited and painful range of motion in his ankle. Significant swelling and bruising in the ankle were observed.
The emergency department nurse cares for a client with right ankle pain.
Complete the statement below:
While teaching the client how to use crutches, the nurse should instruct the client to ambulate using the
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Choice A rationale: A three-point gait is used when one leg is weaker or injured and cannot bear weight. The client should place the crutches about 12 inches in front of the feet and lean forward on the crutches. Then, the client should lift the injured leg and
swing the body forward between the crutches, landing on the uninjured leg. The client should not put any weight on the injured ankle, as ordered by the physician.
Choice B rationale: A four-point gait is used when both legs can bear some weight, but one is weaker than the other.
Choice C rationale: A swing-through gait is used when both legs can bear weight, but need assistance with balance and coordination.
Choice D rationale: A two-point gait is used when both legs have equal strength and can bear full weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Metronidazole is not typically used to treat genital warts caused by HPV.
Choice B rationale: HPV can be transmitted through various forms of sexual contact, including oral sex.
Choice C rationale: Condoms reduce but do not eliminate the risk of HPV transmission. Choice D rationale: Genital warts caused by HPV increase the risk of cervical cancer,
necessitating regular Pap smears for monitoring and early detection.
Correct Answer is B
Explanation
Choice A rationale: Rotating the neck to one side while observing the eyes moving to the opposite side is a procedure for testing for oculocephalic reflex or doll's eye
phenomenon, which indicates brainstem function.
Choice B rationale: This is the correct answer. Kernig's sign is a clinical sign that indicates meningitis, which is an inflammation of the membranes that cover the brain and spinal cord. To test for Kernig's sign, the nurse should flex the patient's hip to 90 degrees and then attempt to extend the knee. A positive Kernig's sign is when the patient
experiences pain in the lower back or hamstring, resists knee extension, or involuntarily flexes the opposite leg.
Choice C rationale: Stroking the lateral aspect of the sole of the patient's foot and observing for dorsiflexion of the big toe is a procedure for testing for Babinski's sign, which indicates upper motor neuron lesion or damage.
Choice D rationale: Passively flexing the patient's neck forward and observing for hip and knee flexion is a procedure for testing for Brudzinski's sign, which also indicates meningitis.
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