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 C
Explanation
A. Advise the family that a spiritual advisor will explain what life-sustaining measures are: While spiritual advisors can provide support, the nurse should focus on ensuring the client understands their rights and options rather than delegating decision-making explanations to family or advisors. The client’s autonomy is the priority.
B. Intervene if the client makes a health care decision the nurse does not agree with: The nurse must respect the client’s autonomy and decisions regarding their care, even if they personally disagree. Intervening based on personal beliefs violates ethical and legal principles of patient rights.
C. Ensure the client has identified a health care surrogate: Helping the client designate a health care surrogate ensures that someone is authorized to make decisions if the client becomes incapacitated. This is a critical step in advance care planning and aligns with legal and ethical standards.
D. Inform the client that once advance directives have been agreed upon, no changes can be implemented: Advance directives can be updated or revoked at any time while the client is competent. Providing inaccurate information could limit the client’s rights and autonomy, so the nurse should clarify that changes are always possible.
Correct Answer is C
Explanation
A. Change the client's position every 2 hr: Repositioning helps prevent skin breakdown and promotes circulation, which is important for stroke clients. However, it does not address the most immediate risk associated with right-sided weakness and facial drooping.
B. Place the client's right hand in a supination position: Proper positioning of the affected extremities prevents contractures and maintains joint alignment. While necessary for long-term care, it is not the highest priority in the immediate post-stroke period.
C. Maintain NPO status for the client: Right-sided weakness and facial drooping indicate potential dysphagia, placing the client at high risk for aspiration. Maintaining NPO status until a swallowing assessment is completed is the priority to prevent aspiration pneumonia, which is a life-threatening complication.
D. Perform range-of-motion exercises to the client's extremities: Range-of-motion exercises prevent contractures and maintain mobility. While important, this intervention is secondary to ensuring the client’s airway safety and preventing aspiration.
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