A nurse is observing a client who has right-sided weakness ambulate using a cane. Which of the following actions by the client should alert the nurse that further teaching is necessary?
The client holds the cane on the affected side.
The client keeps two points of support on the ground.
The client advances the cane before moving the unaffected leg.
The client supports his weight on both legs when moving the cane forward.
The Correct Answer is A
A) The client should hold the cane on the unaffected side to provide support for the affected side, which is weaker. Holding the cane on the affected side does not offer the necessary support and balance needed during ambulation, indicating a need for further teaching.
B) Keeping two points of support on the ground, such as one foot and the cane or both feet, is a safe practice that ensures stability while ambulating, so no further teaching is necessary for this action.
C) Advancing the cane before moving the unaffected leg is the correct technique. The cane should be moved first, followed by the affected leg, and then the unaffected leg, to maintain balance and support.
D) Supporting weight on both legs when moving the cane forward is appropriate as it provides a stable base and prevents the client from falling, indicating that the client understands the correct use of the cane.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Having vision checked is a positive step to prevent falls by addressing potential visual impairments.
B. Wearing socks when getting out of bed increases the risk of slipping, indicating a need for further teaching.
C. Placing a safety bar near the toilet is a preventive measure against falls.
D. Putting a night-light in the hallway helps improve visibility and reduce the risk of tripping
Correct Answer is B
Explanation
A. Wearing cotton socks is appropriate as they allow for better air circulation.
B. Cutting nails rounded at the corners can lead to ingrown toenails, which is not recommended for individuals with diabetes.
C. Using a mirror for daily foot inspection is a good practice to identify any issues early.
D. Buying shoes late in the afternoon accounts for any swelling that may occur during the day, which is a suitable practice for individuals with diabetes.
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