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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","A","C","D"]
Explanation
A. Check the client's gastric residual: After confirming tube placement, gastric residual is assessed to evaluate delayed gastric emptying, which could increase the risk of aspiration. This is done before administering medications or feedings.
B. Verify the tube placement: Tube placement is verified first to ensure the medication is delivered into the stomach and not the lungs. This prevents aspiration and other complications associated with incorrect tube placement.
C. Pour the medication into the syringe and allow it to flow by gravity: Once placement is confirmed and residual checked, the medication is administered via gravity through the syringe to minimize pressure on the NG tube and promote safe delivery.
D. Clamp the NG tube for 20 to 30 min: After administering the medication, the NG tube is clamped to allow for medication absorption before suction is resumed. Immediate suctioning would remove the medication before it can take effect.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
- Aspiration: The client reports food getting stuck in the mouth and has a hoarse voice, which are classic signs of dysphagia (difficulty swallowing). Dysphagia significantly increases the risk for aspiration, where food or liquid enters the airway instead of the esophagus.
- Neurological status: The client also has left-sided weakness, suggesting a neurologic impairment (possibly from a stroke or similar event), which can affect swallowing coordination and airway protection.
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