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. Hypoactivity: Hypoactive bowel sounds refer to reduced or diminished intestinal activity, often indicating slowed motility. These sounds are usually soft, infrequent, or absent, which contrasts with the loud, growling sounds described in this scenario.

B. Paralytic ileus: Paralytic ileus is a condition characterized by the absence of intestinal motility, resulting in no bowel sounds on auscultation. The presence of loud growling sounds indicates active bowel movements, making paralytic ileus an unlikely term.

C. Borborygmi: Borborygmi describes the loud, rumbling, growling, or gurgling sounds caused by the movement of gas and fluids through the intestines. These sounds are normal but can be louder than usual in cases of increased gastrointestinal activity, such as hunger or diarrhea.

D. Distention: Distention refers to the visible swelling or enlargement of the abdomen, often due to gas, fluid, or mass accumulation. It is a physical finding observed visually or by palpation, not a term for a type of bowel sound heard during auscultation.

A. Oriented to person only B. Hearing acuity intact C. Ability to use call light D. Full range of motion bilateral lower extremities

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.

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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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