A nurse is assisting a client who has received crutches in an urgent care center following a foot injury. Which of the following statements should the nurse identify as an indication that the client needs additional teaching?
“I will bear the weight of my body on my hands.”
"I have a set of my brother's old crutches in my basement I can also use."
“I will keep spare crutch tips handy.”
“I will inspect my crutches every day for signs of wear.”
Correct Answer : A,B
Choice A rationale: Bearing the weight of the body on the hands is not the correct technique for using crutches. The weight should be borne on the arms, not the hands.
Choice B rationale: Using crutches that belonged to someone else may not be appropriate as they need to be properly fitted for the individual. Additionally, old crutches may be worn or damaged.
Choice C rationale: This statement is appropriate and does not indicate a need for additional teaching. Keeping spare crutch tips is a good practice, as crutch tips can wear down over time and may need replacement. This demonstrates the client's understanding of the need for maintenance and preparedness.
Choice D rationale: This statement is appropriate and indicates a good understanding of crutch care. Regular inspection of crutches is important to ensure their safety and effectiveness. It allows the client to identify any signs of wear or damage early on and take necessary actions, such as replacing worn-out parts, to prevent accidents or injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: An unstageable ulcer is covered with slough or eschar, making it difficult to determine the depth of tissue involvement. The presence of eschar prevents accurate staging of the wound.
Choice B rationale: Stage II pressure ulcers involve partial-thickness skin loss, typically presenting as a shallow open ulcer with a red-pink wound bed.
Choice C rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, which is not described in this scenario.
Choice D rationale: Stage III pressure ulcers involve full-thickness tissue loss without exposed bone, tendon, or muscle, but the presence of eschar makes accurate staging challenging.
Correct Answer is A
Explanation
Choice A rationale: Stool expelled into an ileostomy bag is often of liquid consistency. An ileostomy involves the diversion of the small intestine, where the stool is more liquid compared to a colostomy, which involves the large intestine and typically produces more formed stool.
Choice B rationale: Bloody stool is not a typical characteristic of stool from an ileostomy.
Choice C rationale: Mucus-filled stool is not the primary characteristic of stool from an ileostomy.
Choice D rationale: Soft semi-formed stool is not typical of an ileostomy; the stool is more liquid in consistency.
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