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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 C

Explanation

The correct answer is choice C. The nurse should ask the client what the voices are telling them, because this can help assess the client’s risk for harm to self or others, and also show empathy and respect for the client’s experience.

The nurse should not assume that the client’s hallucinations are related to medication noncompliance, as this can be perceived as accusatory and judgmental (choice A).

The nurse should not focus on the duration of the hallucinations, as this is not the priority at this time (choice B).

The nurse should not invalidate the client’s reality by stating that they do not hear anything, as this can cause mistrust and alienation (choice D).

The nurse should use therapeutic communication techniques to establish rapport and safety with the client who has schizophrenia.

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