A nurse is monitoring a client who ambulates with a cane. Which of the following actions by the client should the nurse expect?

The client holds the cane on the stronger side of their body.

The top of the cane is at the same height as the client's waist.

The client moves their stronger leg forward first.

The client advances the cane forward 12.7 cm (5 in).

Answer and Explanation

The Correct Answer is A

A. The client holds the cane on the stronger side of their body.: Holding the cane on the unaffected (stronger) side provides a wider base of support and shifts weight away from the weaker leg.

B. The top of the cane is at the same height as the client's waist.: The top of the cane should reach the level of the greater trochanter or the wrist crease.

C. The client moves their stronger leg forward first.: The cane and the weaker leg should move forward together first, followed by the stronger leg.

D. The client advances the cane forward 12.7 cm (5 in).: Standard instruction is to advance the cane 15 to 25 cm (6 to 10 inches) to maintain stability.

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Correct Answer is C

Explanation

A. Tongue depressor: This is typically used for oral examinations or as a splint for small digits, not for wound assessment.

B. Syringe: While a syringe might be used for wound irrigation, it is not the primary tool for collecting data or measuring the wound's physical characteristics.

C. Cotton-tipped applicator: A stage 4 pressure injury involves full-thickness tissue loss with exposed bone, tendon, or muscle. A cotton-tipped applicator is used to measure the depth of the wound and to check for tunneling or undermining.

D. Adhesive tape: This is used to secure a dressing but does not assist in the data collection/assessment of the wound itself.

A. Check for a positive Babinski reflex. B. Have the client perform heel-to-toe walking. C. Perform the Romberg test. D. Have the client lie in bed and use his heel to draw a line on the opposite shin. E. Perform Weber's test.

Correct Answer is ["B","C"]

Explanation

A. Check for a positive Babinski reflex.: This is used to assess upper motor neuron dysfunction, not balance.

B. Have the client perform heel-to-toe walking.: This (tandem walking) tests cerebellar function and the client's ability to maintain an upright posture while moving.

C. Perform the Romberg test.: The Romberg test assesses balance by having the client stand with feet together and eyes closed; significant swaying indicates a loss of balance.

D. Have the client lie in bed and use his heel to draw a line on the opposite shin.: This (heel-to-shin test) assesses coordination, but since the client is lying down, it does not test balance.

E. Perform Weber's test.: This is a hearing test used to determine if sound is heard equally in both ears.

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A nurse is monitoring a client who ambulates with a cane. Which of the following actions by the client should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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