A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?
"Advance the cane 12 inches forward when walking."
"Hold the cane on the side of your affected leg when walking."
"Keep the cane at the same level as the affected leg when climbing stairs."
"Move your unaffected leg before your affected leg when walking."
The Correct Answer is D
A. Advancing the cane 12 inches forward when walking is not a standard instruction for cane use. Typically, the cane is advanced a short distance ahead of the individual's affected leg to provide support and stability during ambulation.
B. Holding the cane on the side of the affected leg does not provide adequate support and stability to the affected side while walking.
C. When climbing stairs, the cane should be held in the hand opposite the affected leg to provide support and balance. Placing the cane at the same level as the affected leg may
lead to imbalance and difficulty ascending stairs safely.
D. This is because when using a cane for ambulation, the cane should be held on the stronger side of the body, and the user should move the cane forward simultaneously with the affected (weaker) leg. Then, the stronger leg is moved forward, which helps in maintaining balance and stability during walking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The first priority in any emergency situation is to ensure personal safety. The nurse should immediately walk to a safe area, away from the smoke and potential danger,
before taking further action.
B. While closing doors can help contain smoke and fire, personal safety takes
precedence. The nurse should prioritize evacuating to a safe location before attempting to close doors.
C. Wrapping clients in blankets may not be appropriate in this situation, as it does not address the immediate threat posed by the smoke and potential fire. Ensuring personal safety is the priority.
D. While staying close to the ground can reduce exposure to smoke and toxic fumes in some situations, it is not the first action to take. Evacuating to a safe area is the most
important step to protect oneself from harm.
Correct Answer is B
Explanation
A. Atelectasis refers to the collapse of lung tissue due to blockage or pressure on the airways, commonly caused by immobility but primarily affects the respiratory system.
B. Peristalsis is the natural movement of the intestines that propels food and waste products through the digestive tract. Immobility can lead to decreased peristalsis, causing constipation and other gastrointestinal issues.
C. Shearing refers to the force that causes layers of tissue to move on each other, often leading to skin breakdown and pressure ulcers. It is not directly related to
the gastrointestinal system.
D. Deep vein thrombosis (DVT) is the formation of blood clots in deep veins,
typically in the legs, due to reduced blood flow and stasis caused by immobility. It primarily affects the circulatory system, not the gastrointestinal system.
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