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
Stepping with his affected leg first when going up stairs
Positioning both hands on the grips with his elbows slightly flexed
Supporting his body weight while leaning on the axillary crutch pads
The Correct Answer is C
The correct answer is a. Moving both crutches with the stronger leg forward first.
Rationale for Choice C:
- Proper positioning of the hands on the grips and keeping the elbows slightly flexed helps ensure stability and control while using the crutches.
Rationale for Other Choices:
a. In a three-point gait, the client moves both crutches and the affected leg together, followed by the unaffected leg. The stronger leg does not move forward first.
b. Stepping with the affected leg first when going up stairs: This action is incorrect for the three-point gait. When ascending stairs, the client should move the stronger leg up first, followed by the crutches and the affected leg.
d. Supporting his body weight while leaning on the axillary crutch pads: This action is also correct for general crutch use, but it does not specifically address the weight-bearing restrictions and movement pattern of the three-point gait.
Additional Information:
- Practice and supervision: It's essential for the client to practice the three-point gait under the supervision of a healthcare professional to ensure proper technique and safety.
- Gradual progression: The client should gradually increase their distance and duration of crutch use as their strength and coordination improve.
- Pain management: Adequate pain management is crucial to allow the client to participate in rehabilitation and regain mobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. Incorrect. Documenting the client's understanding of adverse effects is important, but ensuring the client's knowledge about diaphragm use is the first step.
B. Incorrect. Teaching the client how to insert the diaphragm can be an important step, but first, it's essential to assess the client's existing knowledge.
C. Correct. Before proceeding with teaching or other actions, it's important to determine the client's baseline understanding of diaphragm use.
D. Incorrect. Supervising the return demonstration is important but should come after the client's knowledge level is assessed.
Correct Answer is D
Explanation
A. Incorrect. Rubella is not transmitted via airborne routes. Droplet precautions are typically not required for rubella.
B. Incorrect. Koplik spots are a characteristic of measles, not rubella.
C. Incorrect. Aspirin administration is contraindicated in adolescents with viral infections due to the risk of Reye's syndrome.
D. Correct. Rubella is a teratogenic virus that can cause birth defects in pregnant women who are exposed to the virus. Isolation from pregnant staff members is important to prevent potential transmission.
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