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A nurse is providing teaching about the use of crutches using a three-point gait to a client who has a tibia fracture.

Which of the following actions by the client indicates an understanding of the teaching?

A.

Moving both crutches with the stronger leg forward first.

B.

Supporting his body weight while leaning on the axillary crutch pads

C.

Stepping with his affected leg first when going up stairs

D.

Positioning both hands on the grips with his elbows slightly flexed.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice d. Positioning both hands on the grips with his elbows slightly flexed.

Choice A rationale:

  • Moving both crutches with the stronger leg forward first is incorrect for a three-point gait. This describes a two-point gait, which is used when a client can bear weight on both legs. In a three-point gait, the client bears weight on the unaffected leg and the crutches, not the stronger leg.
  • This action would put excessive weight on the affected leg and could potentially compromise healing or cause further injury.

Choice B rationale:

  • Supporting his body weight while leaning on the axillary crutch pads is also incorrect. This can lead to nerve damage in the armpits and should be avoided.
  • The weight should be distributed through the hands and wrists, not the armpits.

Choice C rationale:

  • Stepping with his affected leg first when going up stairs is incorrect and potentially dangerous. The client should lead with the stronger leg when going up stairs to maintain balance and control.

Choice D rationale:

  • Positioning both hands on the grips with his elbows slightly flexed is the correct action for using crutches with a three-point gait. This allows for proper weight distribution, balance, and control of the crutches.
  • It also helps to prevent fatigue and strain in the arms and shoulders.

Key points to remember about the three-point gait:

  • Weight is borne on the unaffected leg and the crutches, not the affected leg.
  • The crutches and the unaffected leg move forward together, followed by the affected leg.
  • The client should look ahead, not down at their feet.
  • The client should take small, even steps.
  • The client should rest as needed.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale: Calling in additional staff is typically a function of the nursing supervisor or the hospital’s incident command center, rather than the responsibility of a single medical-surgical unit nurse.

Choice B rationale: Acting as a media liaison is the role of the Public Information Officer. Nurses must maintain patient confidentiality and follow the established chain of command during a mass casualty event.

Choice C rationale: Determining the needs of incoming clients (triage) is performed by emergency department staff or designated triage officers at the scene, not by nurses working on a medical-surgical inpatient unit.

Choice D rationale: To create bed capacity for incoming disaster victims, the medical-surgical nurse identifies stable clients who can safely be discharged or transferred, recommending these specific individuals to the healthcare provider.

Correct Answer is D

Explanation

The correct answer is choiced. A client who is taking warfarin and has an INR of 1.8.

Choice A rationale:

An induration after a Mantoux test indicates a positive reaction, but it does not necessarily require immediate follow-up unless the induration is significant and the client has risk factors for tuberculosis.

Choice B rationale:

Sodium phosphate is commonly used as a bowel preparation for colonoscopy. This does not typically require follow-up unless the client experiences adverse effects such as dehydration or electrolyte imbalance.

Choice C rationale:

A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L). Therefore, this finding does not require follow-up.

Choice D rationale:

An INR of 1.8 for a client taking warfarin is below the therapeutic range for most indications (typically 2.0-3.0). This requires follow-up to adjust the warfarin dosage to achieve the desired anticoagulation effect.

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