A nurse is providing discharge instructions to a client about proper use of a cane for maximum support. Which of the following statements by the client indicates an understanding of the teaching?
"I will hold my cane on my stronger side."
"I should hold my cane 12 inches from my side."
"I will keep my elbow flexed at a 90-degree angle while moving my cane."
"I should move my weaker leg before moving my cane."
The Correct Answer is A
A. "I will hold my cane on my stronger side." The cane should be held on the stronger (unaffected) side to provide better support and stability while allowing the weaker leg to move more freely.
B. "I should hold my cane 12 inches from my side." The cane should be positioned about 6–10 inches to the side of the foot to ensure proper balance and support.
C. "I will keep my elbow flexed at a 90-degree angle while moving my cane." The elbow should be flexed at about 15–30 degrees, not 90 degrees, to maintain comfort and proper control of the cane.
D. "I should move my weaker leg before moving my cane." The correct sequence is to move the cane first, then move the weaker leg forward, followed by the stronger leg, which provides better stability and reduces fall risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Instruct the client to take small sips of water."
Having the client take small sips of water helps the nurse observe the thyroid gland as it moves up and down with swallowing, making abnormalities more noticeable.
B. "Ask the client to hyperextend their neck during palpation."
The client should slightly extend (not hyperextend) their neck to relax the muscles and allow for better palpation of the thyroid gland.
C. "Inspect the isthmus as the client holds their breath for 5 seconds."
The thyroid gland is best observed during swallowing, not by holding the breath.
D. "Assist the client to a supine position prior to the assessment."
Thyroid assessment is performed with the client in a sitting or standing position, not lying down.
Correct Answer is B
Explanation
A. "An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids." –
Monitoring IV sites requires assessment skills and clinical judgment, which are within the scope of a licensed nurse, not assistive personnel.
B. "An AP may count the respirations of a client who is going to have surgery later the same day." –
Counting respirations is a basic task within the AP’s scope of practice. However, the nurse is responsible for interpreting the findings.
C. "An AP may take orthostatic blood pressure measurements from a client who reports dizziness." –
Measuring orthostatic blood pressure requires critical thinking and assessment of the client’s condition, which falls under the nurse’s responsibilities.
D. "An AP may perform a central line dressing change for a client who is ready for discharge." –
Performing a central line dressing change is a sterile procedure that requires nursing assessment and should be completed by a licensed nurse.
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