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 A
Explanation
A. Interlock their fingers and hold their hands away from their body above their waist: This position maintains the sterility of the gloves by keeping the hands visible and above waist level, which is the accepted sterile field boundary.
B. Keep their arms at the sides of their body with their hands in a relaxed position: Keeping hands close to the body or at the sides risks contamination because the hands might touch nonsterile surfaces or the body, which is outside the sterile field.
C. Place one hand over the other against the part of the gown covering their upper body: Touching the gown, which is considered sterile only in the front above the waist, can risk contamination if hands move unexpectedly or if the gown surface is touched by nonsterile areas.
D. Clasp their hands together in a relaxed position behind their body at their waist: Positioning hands behind the back limits visibility and control over the sterile field, increasing the risk of contamination by touching nonsterile surfaces or moving out of the sterile boundary.
Correct Answer is D
Explanation
A. Close-up of eyes with yellow sclera: Could indicate jaundice or liver dysfunction, which is not an expected part of aging and requires further evaluation.
B. Older adult man with a rounded back and head tilted forward: Suggests kyphosis, which can occur with aging but is usually linked to osteoporosis or vertebral fractures, not considered an inevitable, expected change.
C. Close-up of nose with a reddish-purple spot (possible bruise): Might result from trauma, coagulopathy, or medication side effects like anticoagulants, not a routine age-related change.
D. Hands with prominent veins, thin skin, and wrinkles: Thinning skin due to decreased subcutaneous fat. Wrinkles from reduced skin elasticity. Prominent veins due to loss of skin turgor and connective tissue. These are all normal physical findings in older adults.
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