A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

Check that the client lifts the walker and then places it down in front of her.

Walk in front of the client to guide her in moving the walker.

Have the client move one leg forward with the walker.

Make sure that the upper bar of the walker is level with the client’s waist.

Answer and Explanation

The Correct Answer is A

A. Check that the client lifts the walker and then places it down in front of her.

To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.

B. Walk in front of the client to guide her in moving the walker.

The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.

C. Have the client move one leg forward with the walker.

The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.

D. Make sure that the upper bar of the walker is level with the client’s waist.

The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.

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Correct Answer is C

Explanation

A. Xerostomia

Xerostomia is dry mouth, a condition where the salivary glands do not produce enough saliva. It can have various causes, including medications, medical conditions, or dehydration. Xerostomia is not directly related to teeth grinding.

B. Halitosis

Halitosis is bad breath. While dental issues, including bruxism (teeth grinding), can contribute to bad breath, halitosis itself does not specifically describe teeth grinding.

C. Bruxism

Bruxism is the medical term for teeth grinding or clenching, especially during sleep. If a client suspects or reports grinding their teeth at night, it is appropriate to document and discuss the issue as bruxism. Bruxism can lead to dental problems, jaw pain, and headaches.

D. Sordes

Sordes refers to a collection of foul matter, such as debris or crusted material, around the mouth. It is not related to teeth grinding.

A. Kidney beans B. Grilled salmon C. Peanut butter D. Raw spinach

Correct Answer is B

Explanation

A. Kidney beans

Kidney beans are a good plant-based source of protein. They contain essential amino acids, but plant-based proteins may lack some amino acids found in animal-based sources. While kidney beans contribute to protein intake, they are not considered the best source of protein for wound healing among the given options.

B. Grilled salmon

Grilled salmon is indicated as the best source of protein for wound healing among the options. Salmon is an animal-based source that provides high-quality protein with all essential amino acids. It is also rich in omega-3 fatty acids, which have anti-inflammatory properties and can further support the healing process.

C. Peanut butter

Peanut butter is a source of protein, but it is also high in fats. While it can contribute to protein intake, it may not be as lean a source as grilled salmon. It's important to consider the overall nutritional profile when recommending it for wound healing.

D. Raw spinach

Spinach is a source of protein, but it is considered a plant-based protein. While it can contribute to overall protein intake, plant-based proteins may not provide as much protein per serving as animal-based sources like salmon. It also contains other nutrients, such as iron and vitamins, which are beneficial but not specifically highlighted for wound healing in this context.

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A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?

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Explanation

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Correct Answer is B

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