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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Locks the wheelchair after transferring the client: Locking the wheelchair should occur before the transfer to prevent it from rolling during the movement. Locking it after transferring compromises client safety and increases the risk of falls or injury.
B. Places the bed in a high position before transferring the client to the wheelchair: The bed should be placed in the lowest safe position to allow the client’s feet to touch the floor and to ease the transition to a lower surface like a wheelchair. A high bed position creates an unsafe height differential.
C. Uses a narrow stance when assisting the client to the wheelchair: A wide stance provides a stronger, more stable base of support, which is essential for safe body mechanics during a transfer. A narrow stance can lead to imbalance and injury to the AP or client.
D. Positions the wheelchair parallel to the client's bed: Positioning the wheelchair parallel or at a slight angle to the bed allows for easier and safer transfers. This minimizes turning and supports a smoother pivot, reducing strain on both the client and caregiver.
Correct Answer is C
Explanation
A. Tell the client to think about something else: Redirecting the client's thoughts without addressing their emotional distress can be dismissive. It does not support emotional processing or help the nurse assess the client’s coping needs.
B. Tell the client that everything will be okay: Offering false reassurance minimizes the client’s feelings and may hinder open communication. It does not validate their experience or help develop coping strategies.
C. Ask the client to describe their support system: Exploring the client’s support system helps assess available emotional and practical resources. This information is essential in planning appropriate interventions and enhancing coping capacity.
D. Ask the client why they're unable to cope: "Why" questions can make clients feel defensive and judged. It is more therapeutic to use open-ended questions that invite sharing without implying blame.
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