A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

The client advances their right foot to meet their left foot.

The client maintains two points of support on the floor.

The client holds the cane in their left hand.

The client moves the cane forward 50.8 cm (20 in) when ambulating.

Answer and Explanation

The Correct Answer is B

B. When using a quad cane, the client should always maintain two points of support on the floor: the cane and either the affected (left) or unaffected (right) leg. This ensures stability and support while walking.

A When using a quad cane, the client should advance their weaker (left) foot and then the stronger (right) foot. This allows the cane to provide support on the weaker side.

C. This action is correct for a client with left-sided hemiparesis. The quad cane should be held on the stronger side (right hand) to provide support for the weaker side (left leg).

D. This statement is unclear in terms of the context provided. However, typically when using a quad cane, the cane is moved forward a comfortable distance with each step to provide continuous support and balance. The exact distance may vary depending on the client's stride length and comfort.

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Correct Answer is C

Explanation

C. Restlessness and agitation can be early signs of increased ICP. They result from the brain's attempt to compensate for the increasing pressure. Restlessness may indicate discomfort or confusion caused by cerebral edema or pressure on brain structures.

A Projectile vomiting can occur with increased ICP due to stimulation of the vomiting center in the brainstem as a response to pressure on the brain. It is a symptom that may indicate a more advanced increase in ICP rather than an early manifestation.

B. Papilledema refers to swelling of the optic disc due to increased intracranial pressure transmitting through the optic nerve sheath. It is typically a late manifestation of increased ICP rather than an early one. It requires time for pressure to build up and affect the optic nerve.

D. Decorticate posturing is a type of abnormal posture that can occur with severe brain injury or increased ICP. It involves flexion of the arms, wrists, and fingers with adduction of the upper extremities and extension of the lower extremities. This is typically a later sign of increased ICP

A. Generalized abdominal pain B. Increased heart rate C. Cloudy effluent D. Fever

Correct Answer is C

Explanation

C. Cloudy effluent is one of the earliest and most specific signs of peritonitis. It warrants immediate evaluation and diagnostic testing to confirm the diagnosis and initiate appropriate treatment.

A Generalized abdominal pain is a common symptom of peritonitis but may not be the earliest indication.

B. Tachycardia (increased heart rate) can occur in response to infection or inflammation, including peritonitis. It is a systemic response rather than a localized symptom.

D. Fever can also be associated with peritonitis but may appear later and is not as specific early indicators

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A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?

Correct Answer is C

Explanation

A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

Correct Answer is C

Explanation

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