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. "I'll use focused breathing to control my pain." B. "I'll listen to my favorite music to take my mind off the pain." C. "I'll think about my grandfather's farm to reduce pain." D. "I'll learn to notice the sensation of muscle tension."

Correct Answer is C

Explanation

A. "I'll use focused breathing to control my pain." Focused breathing is a relaxation technique, but it is distinct from guided imagery. Guided imagery specifically involves creating vivid mental pictures to distract and soothe the mind.

B. "I'll listen to my favourite music to take my mind off the pain." Listening to music is a form of distraction or music therapy, which can help with pain management but is different from guided imagery, which relies on mental visualization.

C. "I'll think about my grandfather's farm to reduce pain." This statement reflects guided imagery, where the client mentally pictures a peaceful, pleasant scene to divert attention from pain and promote relaxation, showing understanding of the technique.

D. "I'll learn to notice the sensation of muscle tension." Noticing muscle tension is related to mindfulness or biofeedback, focusing on awareness of bodily sensations rather than the visualization involved in guided imagery.

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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?

Nursing Test Bank

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