A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicates an understanding of the teaching?
The client leans on the crutches for support while standing still.
The client advances the unaffected leg first while climbing stairs.
The client stands 5 cm (2 in) from the front of a chair before sitting.
The client bears weight on their axilla while standing in the tripod position.
The Correct Answer is B
A: Incorrect. Leaning on the crutches for support while standing still is not the correct way to use crutches. It can lead to discomfort and instability.
B: Correct. The client should advance the unaffected leg first while climbing stairs when using crutches. This technique ensures better stability and safety during stair ascent.
C: Incorrect. Standing 5 cm (2 in) from the front of a chair before sitting is not directly related to the use of crutches.
D: Incorrect. Bearing weight on the axilla while standing in the tripod position is not the correct way to use crutches. The tripod position is used for resting, not weight bearing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Discontinued medications do not provide actionable information for the receiving facility, as they are no longer relevant to the client's ongoing care. Including this information may lead to confusion about the current treatment plan.
B. Resolved health conditions are not a priority to communicate because they do not require further monitoring or intervention. Focus should be placed on active health concerns and ongoing care needs.
C. The frequency of vital sign collection is critical information for the receiving facility to maintain continuity of care and ensure appropriate monitoring of the client's condition. This detail helps guide the long-term care staff in managing the client’s ongoing health needs effectively.
D. Completed nursing interventions are not typically included in the transfer report as they have already been addressed and do not impact future care. The focus should remain on ongoing and future interventions required for the client.
Correct Answer is C
Explanation
A: The client's statement reflects feelings of confusion but does not indicate immediate harm or danger to themselves. It requires therapeutic communication and support but not immediate action.
B: The client's statement expresses concern about their future relationships but does not indicate immediate harm or danger to themselves. It requires support and counseling but not immediate action.
C: Correct. The client's statement suggests significant emotional distress and a potential risk for self-harm or suicidal ideation. Immediate action is required to assess the client's safety and provide appropriate interventions, such as involving a mental health professional.
D: The client's statement indicates dissatisfaction or regret about the mastectomy decision but does not indicate immediate harm or danger to themselves. It requires supportive communication and addressing concerns but not immediate action.
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