A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Confer with the physical therapist for correct crutch size.

Ask the client to sit down while the crutch length is adjusted.

Assess the client for signs of diminished circulation in the hands.

Proceed with teaching the client how to walk with the crutches.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Proceed with teaching the client how to walk with the crutches.

Choice A rationale:

Confer with the physical therapist for correct crutch size. This is unnecessary because the crutches are already correctly fitted. A space of three finger widths between the top of the crutch and the client’s axilla is appropriate to prevent pressure on the axilla and potential nerve damage.

Choice B rationale:

Ask the client to sit down while the crutch length is adjusted. This action is not needed since the crutches are already properly adjusted. Adjusting the crutch length further could lead to improper fitting, which might cause discomfort or injury.

Choice C rationale:

Assess the client for signs of diminished circulation in the hands. While assessing circulation is important, it is not directly related to the fitting of the crutches. Proper crutch fitting focuses on ensuring there is no pressure on the axilla and that the client can use the crutches comfortably.

Choice D rationale:

Proceed with teaching the client how to walk with the crutches. This is the correct action because the crutches are already properly fitted. The nurse should now focus on educating the client on the correct use of the crutches to ensure safe and effective mobility.

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Correct Answer is ["A","C","D"]

Explanation

The correct answer isChoice A, Choice C, and Choice D.

Choice A rationale:A shuffling gait can indicate mobility issues, making it difficult for the client to safely perform foot care and toenail clipping. This increases the risk of falls and injuries.

Choice B rationale:Urinary incontinence does not directly affect the ability to perform foot care or toenail clipping. It is more related to bladder control issues.

Choice C rationale:Syncope when bending suggests that the client may experience dizziness or fainting when bending over, making it unsafe for them to perform foot care and toenail clipping.

Choice D rationale:Hand tremors can make it challenging for the client to handle nail clippers or other tools needed for foot care, increasing the risk of injury.

A. Using two or three people increases client safety. B. The technique is intended to maintain straight spinal alignment. C. Turning instead of pulling reduces the likelihood of skin damage. D. Working together can decrease the risk of back injury to the nurses.

Correct Answer is B

Explanation

Choice A reason: While using multiple people can increase safety, it is not the primary purpose of the log rolling technique.

Choice B reason: The log rolling technique is specifically designed to maintain straight spinal alignment, especially in patients with suspected spinal injuries, to prevent further injury.

Choice C reason: Reducing skin damage is a benefit of proper patient handling, but it is not the main reason for using the log rolling technique.

Choice D reason: Decreasing the risk of back injury to nurses is important, but the primary purpose of the log rolling technique is to protect the patient's spinal integrity.

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A client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger widths between the top of the crutch and the client's axilla. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

Correct Answer is B

Explanation

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