A nurse is reinforcing discharge instructions with a client who is walking with crutches. Which of the following statements by the client indicates an understanding of the instructions?
"I should advance my crutches up the step ahead of my unaffected leg."
"I should keep my elbows straight when I am walking with my crutches."
"I will support my weight on the hand grips of the crutches."
"When I'm walking around my house with my crutches, it's okay to take my shoes off."
The Correct Answer is A
Choice A Reason:
"I should advance my crutches up the step ahead of my unaffected leg." This statement demonstrates correct technique for ascending stairs with crutches. When going up stairs, the client should advance the crutches onto the step first, followed by the unaffected leg.
Choice B Reason:
"I should keep my elbows straight when I am walking with my crutches." The client should maintain a slight bend in the elbows while walking with crutches to provide stability and support.
Choice C Reason:
"I will support my weight on the hand grips of the crutches." The client should not support their weight on the hand grips alone; weight should be distributed through the hands and arms to avoid putting excessive pressure on the axillae.
Choice D Reason:
"When I'm walking around my house with my crutches, it's okay to take my shoes off." It is generally not advisable to walk with crutches without shoes, as wearing shoes provides better support and stability. The client should wear supportive, non-skid footwear while using crutches.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Setting the maximum water heater temperature to 54.4° C (130° F) is appropriate. This temperature is too high and could pose a burn risk, especially for someone with impaired vision who might not easily detect very hot water.
Choice B Reason:
Painting the edges of steps for contrast is appropriate. This measure helps increase visibility by creating a visual contrast between the edges of steps and the surrounding area, aiding the individual in identifying the steps more easily, even with reduced vision.
Choice C Reason:
Securing extension cords across walkways is inappropriate. Placing extension cords across walkways can create tripping hazards, particularly for someone with vision loss who may have difficulty seeing these obstacles.
Choice D Reason:
Using 40-watt bulbs to light hallways is inappropriate. While adequate lighting is crucial for individuals with vision impairment, using only 40-watt bulbs might not provide sufficient illumination. It's recommended to use higher-wattage bulbs or brighter lighting sources to ensure better visibility in the home.
Correct Answer is A
Explanation
Choice A Reason:
"Call me so that I can help you change your position." This response offers practical assistance and comfort to the client. Repositioning can sometimes alleviate discomfort associated with breathing difficulties, and the nurse can offer guidance or physical help to adjust the client's position for improved comfort.
Choice B Reason:
"Try to close your eyes and get some sleep." This response doesn't directly address the client's immediate concern about difficulty breathing and may not offer practical help.
Choice C Reason:
"It is common for breathing to become more difficult as time goes on." While this statement acknowledges the situation, it might not provide the client with actionable guidance or support on how to manage the difficulty in breathing.
Choice D Reason:
"Therapy choices are limited for clients who do not want resuscitation." This response might be interpreted as dismissive or unrelated to the client's immediate needs, focusing more on the DNR order rather than addressing the current concern about breathing difficulties.
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