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 B

Explanation

A. Delegating tasks to appropriate personnel is an important skill, but effective time management also involves personal task completion.

B. Completing activities for one client before moving to the next helps ensure tasks are not left incomplete and promotes organized workflow.

C. Focusing on objectives rather than just activities is a more comprehensive approach to time management, ensuring tasks align with goals.

D. Skipping break times can lead to burnout and decreased efficiency over time, rather than improving time management skills.

A. Clear fluid drainage from the nares B. Report of pain around the eyes C. Dried blood in the mouth D. Mandibular asymmetry

Correct Answer is A

Explanation

A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.

B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.

C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.

D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.

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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

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