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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?

Moving both crutches with the stronger leg forward first.

Supporting his body weight while leaning on the axillary crutch pads

Stepping with his affected leg first when going up stairs

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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Correct Answer is D

Explanation

Answer:D. Troponin T test

Rationale:

A. Creatine kinase (CK) test: While creatine kinase isoenzymes, including CK-MB, can be elevated following myocardial infarction (MI), they are not specific to cardiac muscle injury. CK is found in various tissues throughout the body, so elevated levels can also indicate damage to skeletal muscle or brain tissue, among other sources.

B. Creatine kinase-myocardial band (CK-MB) test: CK-MB is a cardiac-specific isoform of creatine kinase, and elevated levels can indicate myocardial injury, particularly in the context of an acute MI. However, troponin T is a more sensitive and specific marker for myocardial injury.

C. Brain natriuretic peptide (BNP) test: Brain natriuretic peptide is primarily used in the diagnosis and management of heart failure. While elevated BNP levels can indicate heart muscle strain or stress, they are not specific markers for acute myocardial infarction or early injury to the cardiac muscle.

D. Troponin T test: This is the correct answer. Troponin T is a highly specific marker for cardiac muscle injury. Elevated troponin levels can be detected within hours of myocardial infarction and persist for several days, making it an essential tool in the diagnosis of acute coronary syndromes, including myocardial infarction. Troponin T is considered one of the gold standard biomarkers for detecting early injury to the cardiac muscle.

A. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus. B. Complete the Glasgow Coma Scale for a client who has an evolving stroke C. Perform a sterile dressing change for a client who has an abdominal wound D. Perform an admission assessment for a client who is scheduled for surgery

Correct Answer is C

Explanation

The correct answer is choice C. Perform a sterile dressing change for a client who has an abdominal wound. This is because a licensed practical nurse (LPN) can perform tasks that require technical skills and have predictable outcomes, such as dressing changes. A sterile dressing change is also within the scope of practice of an LPN.

Choice A is wrong because complete discharge teaching for a client who has a new diagnosis of diabetes mellitus requires assessment, evaluation and critical thinking, which are beyond the scope of practice of an LPN. Discharge teaching is the responsibility of a registered nurse (RN) who can provide education and counseling to clients and families.

Choice B is wrong because completing the Glasgow Coma Scale for a client who has an evolving stroke requires assessment and interpretation of neurological status, which are complex and unpredictable tasks that only an RN can perform. The Glasgow Coma Scale is a tool that measures the level of consciousness of a client based on eye opening, verbal response and motor response. A client who has an evolving stroke may have changes in their neurological status that require frequent monitoring and intervention by an RN.

Choice D is wrong because performing an admission assessment for a client who is scheduled for surgery requires comprehensive data collection, analysis and synthesis, which are advanced skills that only an RN can perform. An admission assessment involves obtaining a complete health history, performing a physical examination, identifying client needs and problems, and developing a plan of care.

A client who is scheduled for surgery may have complex and unpredictable needs that require specialized knowledge and judgment by an RN.

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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?

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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?