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 A

Explanation

- A) Hyperreflexia is a common symptom of opioid withdrawal, as the nervous system reacts to the absence of the drug. Patients may experience increased reflex actions and muscle spasms due to the sudden change in opioid levels.
- B) Meiosis, or pupil constriction, is not typically a withdrawal symptom; it is more commonly associated with opioid use. During withdrawal, pupils are likely to dilate rather than constrict.
- C) Euphoria is a feeling of intense happiness or excitement, which is often experienced after taking opioids. During withdrawal, individuals are more likely to experience dysphoria, which is a state of unease or dissatisfaction.
- D) Hypothermia is not a recognized symptom of opioid withdrawal. Instead, individuals may experience fever or chills as the body adjusts to the lack of opioids.

A. Have the client tilt her head slightly so that the medication enters the nasolacrimal duct. B. Gently wash away any exudate along the eyelid margin from the outside towards the inner canthus. C. Use aseptic technique and drop the medication into the conjunctival sac. D. Drop prescribed number of drops onto the cornea.

Correct Answer is C

Explanation

A. Tilted head position facilitates drainage into the nasolacrimal duct, not necessarily into the eye.

B. Washing away exudate is not necessary before administering eye drops.

C. Using aseptic technique to drop medication into the conjunctival sac ensures proper delivery of the medication to the eye.

D. Dropping medication onto the cornea can cause discomfort and may not effectively reach the eye.

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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?

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