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

The client moves their stronger leg forward first.

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

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 stronger side improves balance and support while reducing strain on the weaker limb. It also helps coordinate movement and distribute weight more efficiently during ambulation.

B. The client advances the cane forward 12.7 cm (5 in): The cane should typically be advanced 15 to 25 cm (6 to 10 inches) forward for optimal support. Advancing it only 5 inches may provide insufficient balance assistance during walking.

C. The client moves their stronger leg forward first: The weaker leg should move forward after the cane to allow the stronger leg to support most of the weight. This pattern maximizes stability and safety during ambulation.

D. The top of the cane is at the same height as the client's waist: The cane should be level with the wrist crease when the client’s arms are relaxed at their sides, not at waist level. A cane that is too high or low can cause discomfort or improper posture.

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Correct Answer is C

Explanation

A. "Why do you think you are dying?" This question can sound confrontational and may cause the client to feel defensive. It does not acknowledge the client’s feelings or encourage further communication about their concerns.

B. "I think you should have some quiet time to get some rest." While rest is important, this response dismisses the client’s emotional expression and does not address their fear or need for support regarding dying.

C. "You are concerned that you are dying?" This statement reflects the client’s feelings and encourages them to share more about their fears and concerns. It validates their emotions and opens a supportive dialogue.

D. "It is normal to feel this way with your type of cancer." Although normalizing feelings can be helpful, this response might minimize the client’s personal experience and does not directly explore their expressed worry about dying.

A. Gather additional information from the caller to verify their identity. B. Request that the caller contact the client's provider directly for information. C. Ask the caller to contact the client directly for information. D. Provide the caller with a brief update about the client's condition.

Correct Answer is C

Explanation

A. Gather additional information from the caller to verify their identity: Even if the caller's identity is verified, HIPAA regulations prohibit disclosing a client's medical information without the client’s explicit authorization. Verifying identity alone does not grant permission to release confidential health information.

B. Request that the caller contact the client's provider directly for information: Redirecting the caller to the provider does not resolve the issue of confidentiality. Healthcare providers are also bound by HIPAA regulations and cannot release information without proper consent, regardless of who is making the request.

C. Ask the caller to contact the client directly for information: This action respects the client’s privacy and autonomy. Under HIPAA, healthcare professionals may not disclose health information without client authorization. Advising the sibling to speak directly with the client is the appropriate response to safeguard confidentiality.

D. Provide the caller with a brief update about the client's condition: Sharing any health information without the client’s express consent is a violation of HIPAA. Even a brief update constitutes a breach of confidentiality and could result in legal and professional consequences.

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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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