A nurse is caring for a client who is scheduled for surgery.

Exhibit 1

Medical History

0800:

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.

Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points)

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply

A. "Tell me more about your partner." - While exploring the client's feelings about their partner may be relevant to understanding their current emotional state, it does not directly address the statement indicating suicidal ideation. The priority in this situation is to assess the client's risk of self-harm or suicide.

B. "Have you thought about harming yourself?"

This response directly addresses the client's statement expressing thoughts of dying and allows the nurse to assess the client's risk of self-harm or suicide. It opens up a dialogue about the client's feelings and intentions, which is crucial for ensuring their safety and providing appropriate support and intervention.

C. "You should discuss these feelings with your provider." - While encouraging the client to communicate with their healthcare provider is important, it does not address the immediate concern of potential self-harm or suicide. The nurse should assess the client's safety and provide support before encouraging further discussion with the provider.

D. "Why did you stop taking your medication?" - While medication non-adherence may contribute to worsening symptoms of depression, it is not the immediate concern in this situation. The client's statement expressing thoughts of dying requires immediate assessment of suicidal ideation and intervention to ensure their safety.

A. Swing-through gait:

The swing-through gait is a more advanced gait pattern used by clients with significant lower extremity weakness or paralysis. It involves swinging both crutches forward simultaneously, followed by swinging both legs forward past the crutches. This gait is not appropriate for a client who can only bear weight on one leg.

B. Three-point gait:

The three-point gait is typically used when one lower extremity is completely non-weight-bearing. It involves advancing both crutches and then swinging the affected leg through to meet the crutches. Since the client in this scenario can bear weight on one leg, the three-point gait is the most appropriate choice.

C. Four-point alternating gait

Four-point alternating gait
The four-point alternating gait involves a sequence of movements where each crutch and each leg move alternately. The sequence is as follows:

• Move the right crutch forward(injured side).
• Move the left foot forward(non-injured side).
• Move the left crutch forward(non-injured side).
• Move the right foot forward(injured side). This gait offers stability and control but requires more effort and coordination.

D. Two-point alternating gait:

The two-point alternating gait involves moving one crutch and the opposite lower extremity forward simultaneously, followed by moving the other crutch and the opposite lower extremity forward. This gait pattern is typically used by clients who have good balance and strength in both lower extremities. It may not provide enough stability and support for a client who can only bear weight on one leg.