A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care?

Remind the client to place the cane on the unaffected side.

Adjust the length of the cane to equal the distance from the client's iliac crest to the floor.

Remove the rubber tip from the cane to enhance ambulation.

Place the cane safely in the closet during naps and at bedtime.

Answer and Explanation

The Correct Answer is A

A. Placing the cane on the unaffected side helps to provide better support and balance for the client. It allows the client to shift weight away from the affected side, reducing strain and risk of falls.

B. The cane should be adjusted to the height of the wrist crease when the client stands with arms relaxed at their sides, not the iliac crest. This ensures proper posture and effective use of the cane.

C. Removing the rubber tip from the cane is unsafe as the rubber tip provides traction and prevents slipping. Without it, the cane could easily slide on smooth surfaces, increasing the risk of falls.

D. Placing the cane in the closet during naps and bedtime is not practical. The client may need to use the cane immediately upon waking, and it should be easily accessible to prevent accidents.

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Correct Answer is C

Explanation

A. Limit each of the client's visitors to 1 hr per day. - This is not necessary specifically due to the presence of the radiation implant. Visitation restrictions should be based on hospital policy and

the client's condition, not solely on the presence of a radiation implant.

B. Remove dirty linens from the room after double bagging. - This is a standard infection control measure and is not specific to caring for a client with a radiation implant.

C. Wear a dosimeter film badge while in the client's room. - Healthcare workers who care for clients with sealed radiation implants should wear dosimeter film badges to monitor their radiation exposure levels.

D. Ensure family members remain at least 1 m (3.2 feet) from the client. - While limiting exposure to radiation is important, maintaining distance alone may not provide adequate

protection. Healthcare workers should follow appropriate safety precautions and use shielding as necessary when caring for clients with radiation implants.

A. "The provider will notify your parent's employer about admission to the facility." B. "Your parent will have to take the medication that the doctor prescribes." C. "Your parent might have electroconvulsive therapy without providing consent." D. "The provider can prescribe restraints if your parent tries to harm others."

Correct Answer is D

Explanation

A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.

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A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the following nursing actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is talking with an adult child of a client who was involuntarily admitted to an inpatient mental health facility. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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