A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client?
Four-point.
Three-point.
Two-point.
Swing-through.
The Correct Answer is B
The correct answer is choice b. Three-point.
Choice A rationale:
The four-point gait is used when a client can bear weight on both legs. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. This gait provides maximum stability but is not suitable for non-weight-bearing conditions.
Choice B rationale:
The three-point gait is appropriate for clients who cannot bear weight on one leg. In this gait, both crutches and the affected leg move forward together, followed by the unaffected leg. This allows the client to keep weight off the injured leg while moving.
Choice C rationale:
The two-point gait is used when a client can bear partial weight on both legs. It involves moving one crutch and the opposite leg forward simultaneously, followed by the other crutch and leg. This gait is faster than the four-point gait but still provides some stability.
Choice D rationale:
The swing-through gait is used by clients who have good upper body strength and balance. It involves moving both crutches forward together and then swinging both legs forward past the crutches. This gait is not typically recommended for clients who need to keep weight off one leg.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: "Provide mouth care to them at least every 2 hours."
Choice A rationale:
Encouraging meals at least three times daily is not appropriate for a client who is near death. As clients approach the end of life, their appetite often decreases, and they may be unable to tolerate regular meals. It's more important to focus on providing comfort and relief.
Choice B rationale:
Keeping the room warm to help them breathe easier is not necessarily true. While a comfortable room temperature can be important for the client's overall comfort, warmth alone does not significantly impact breathing in the context of impending death. Breathing difficulties at this stage are usually related to physiological changes rather than room temperature.
Choice C rationale:
Helping the client onto their left side if they are experiencing nausea is not a universally applicable instruction. While left-side positioning can help alleviate nausea for some clients, it might not be suitable for everyone. Nausea can be caused by various factors, and the caregiver should assess the client's comfort and preferences before changing their position.
Choice D rationale:
Providing mouth care to the client at least every 2 hours is the most appropriate instruction among the choices. Near the end of life, many clients become less able to maintain their oral hygiene due to various factors, including weakness and reduced consciousness. This can lead to discomfort and potential complications. Regular mouth care helps keep the client's mouth moist and clean, enhancing their overall comfort.
Correct Answer is B
Explanation
The correct answer is choice B. Removing the client's dentures.
Choice A rationale:
Gathering the client's personal belongings is an appropriate action in the postmortem care process. This step allows the family to receive their loved one's belongings, contributing to a compassionate and respectful care process.
Choice B rationale:
Removing the client's dentures requires intervention by the nurse. In postmortem care, dentures should be left in place to maintain the natural appearance of the deceased's face and to ensure that the mouth and lips maintain their proper form.
Choice C rationale:
Placing absorbent pads under the client's buttocks is a common practice to manage any potential leakage of bodily fluids after death. This action helps maintain the cleanliness and dignity of the deceased individual.
Choice D rationale:
Closing the client's eyes is an appropriate action during postmortem care. It provides a peaceful appearance and shows respect for the deceased person.
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