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 A

Explanation

A A change in level of consciousness (LOC), such as confusion, lethargy, or loss of consciousness, can indicate worsening neurological status. It reflects impaired brain function due to increased pressure on brain tissues.

B. Pupillary changes, such as dilation or asymmetry, can occur due to pressure on the oculomotor nerve (cranial nerve III). Pupillary dilation can be a sign of increased ICP but typically occurs after other neurological changes.

C. Decorticate posturing indicates significant neurological impairment but typically appears after alterations in consciousness.

D. Cheyne-Stokes respirations indicate brainstem involvement and impaired respiratory control but are generally seen later in the progression of neurological deterioration.

A. Diphenhydramine<br> B. Spironolactone C. Desmopressin D. Metoclopramide

Correct Answer is A

Explanation

A Diphenhydramine is an antihistamine, which helps reduce allergic reactions like hives and urticaria.

B. Spironolactone is a diuretic and potassium-sparing aldosterone antagonist, primarily used for managing high blood pressure and fluid retention. It's not typically used for allergic reactions.

C. Desmopressin helps control bleeding and is not suitable for allergic reactions.

D. Metoclopramide helps with nausea and vomiting and wouldn't be the first choice for hives and urticaria.

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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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