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 A

Explanation

A. Oriented to person only indicates the client is confused about time, place, or situation, which increases the risk of injury due to impaired judgment and decreased awareness of surroundings. This cognitive impairment can lead to unsafe behaviors like attempting to get out of bed unassisted or wandering.

B. Hearing acuity intact helps the client receive verbal instructions and alarms, reducing injury risk by facilitating communication and timely responses to safety cues. Good hearing supports situational awareness, which is protective against accidents.

C. Ability to use call light allows the client to summon assistance when needed, helping prevent falls or other injuries. This functional independence in communication is a key safety factor in the acute care setting.

D. Full range of motion in bilateral lower extremities indicates good physical mobility and strength, which decreases injury risk by enabling the client to reposition safely and maintain balance during transfers or ambulation.

A. Wait for 4 hr before sending the specimen to the laboratory. B. Avoid collecting the specimen from areas of the stool that contain blood. C. Transfer the specimen to a cup without it touching the outside of the container. D. Collect at least 7.62 cm (3 in) of the client's stool.

Correct Answer is C

Explanation

A. Wait for 4 hr before sending the specimen to the laboratory: Delaying the transport of stool specimens can affect test results by allowing bacterial growth or degradation of components. Specimens should be sent promptly or refrigerated if there is a delay.

B. Avoid collecting the specimen from areas of the stool that contain blood: If testing for occult blood or infection, areas with blood should be included because they provide important diagnostic information, so avoiding them is incorrect.

C. Transfer the specimen to a cup without it touching the outside of the container: Maintaining specimen integrity and preventing contamination is essential. The nurse should ensure the stool does not contact the outside of the container to avoid spreading pathogens and ensure accurate testing.

D. Collect at least 7.62 cm (3 in) of the client's stool: Collecting such a large amount is unnecessary; usually a smaller amount (about 1 inch or walnut size) is sufficient for testing, so this choice is incorrect.

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