A nurse is performing a gait assessment on a client to evaluate the client's ability to perform ADLs. Which of the following findings indicates a standard gait?
The client's shoulders are rounded slightly forward.
The client's heels touch the ground before their toes.
The client's dominant foot bears more weight.
The client looks at the floor when walking.
The Correct Answer is B
A. The client's shoulders are rounded slightly forward: Slightly rounded shoulders can indicate poor posture or musculoskeletal issues. While minor rounding is common, it is not a defining characteristic of a normal, standard gait and may reflect postural deviations.
B. The client's heels touch the ground before their toes: A standard gait involves initial contact with the heel, followed by a smooth rolling motion to the toes during the stance phase. This heel-to-toe pattern indicates normal foot mechanics and weight transfer, reflecting a healthy, functional gait for ADLs.
C. The client's dominant foot bears more weight: Unequal weight bearing between the dominant and non-dominant foot suggests an abnormal gait or musculoskeletal imbalance. In a normal gait, weight is distributed evenly between both lower extremities during walking.
D. The client looks at the floor when walking: Looking at the floor may indicate visual or balance issues, poor confidence, or gait instability. A standard gait typically involves a forward gaze with a stable, upright posture to maintain balance and coordination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ensure that the health care provider has consulted with another team member: While consultation may be part of ethical decision-making, it is not the primary action the nurse should take when a comatose client requires consent. The priority is confirming that informed consent is obtained from the appropriate decision-maker.
B. Ensure that the client's 16-year-old child supports the provider's decision for surgery: Minors cannot legally provide consent for medical procedures. The nurse should focus on the legal health care surrogate or guardian rather than the opinion of a minor child.
C. Determine if the procedure is medically necessary for the client: Assessing medical necessity is the provider’s responsibility. The nurse’s role is to advocate for the client by ensuring informed consent is obtained and the surrogate understands the procedure, risks, and benefits.
D. Determine if the health care surrogate understands the risks and benefits of the procedure: The nurse should confirm that the health care surrogate has received adequate information and understands the risks, benefits, and alternatives to the procedure. This ensures ethical and legal consent is obtained for a client unable to make decisions.
Correct Answer is A
Explanation
A. Recurrent UTI: Frequent urinary tract infections can be a sign of gestational diabetes mellitus (GDM) because hyperglycemia creates an environment conducive to bacterial growth. Recurrent infections may indicate impaired glucose regulation and warrant further screening for GDM.
B. Family history of type 2 diabetes mellitus: While a family history increases the client’s risk for developing GDM, it is not a direct indicator that the client currently has gestational diabetes. It is considered a risk factor rather than a presenting finding.
C. Heart rate is consistently between 55/min and 58/min: A slightly lower maternal heart rate is not indicative of gestational diabetes. Maternal bradycardia in this range is usually not related to glucose metabolism and may be influenced by other factors such as fitness level or medication use.
D. Reports decrease in urination frequency: Gestational diabetes typically causes polyuria rather than decreased urination. Reduced urination is not a characteristic finding associated with GDM and may suggest other renal or hydration issues instead.
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