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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The list of medications is typically included in the Background component of the ISBARR communication tool, as it provides important information about the client's ongoing treatment and medications.

B. Treatment plans and interventions are generally discussed in the Assessment and Recommendation components of the ISBARR communication tool, as they involve the nurse's assessment of the client's condition and the actions recommended for continued care.
C. The Situation component of the ISBARR communication tool focuses on providing a concise summary of the client's current medical condition or status, including relevant changes since the last report or significant events that occurred during the shift.
D. Vital signs may be included as part of the Background or Assessment components of the ISBARR communication tool, depending on their relevance to the client's current condition and any changes observed during the shift.

A. Maximum assist B. Minimal assist C. Moderate assist D. No assist

Correct Answer is B

Explanation

A. Maximum assist is when the client requires total assistance from one or more persons to perform the activity. In this scenario, the client is able to rise from a seated position
independently with the assistance of a cane, so maximum assist is not appropriate.
B. Minimal assist is when the client requires some assistance or supervision to perform the activity but is able to complete most of the task independently. Since the client can rise from a seated position using a cane for support, they require minimal assistance.
C. Moderate assist is when the client requires more help than minimal assist but can still contribute to the activity. Since the client can perform the task with minimal assistance, moderate assist is not appropriate.
D. No assist is when the client is able to perform the activity without any assistance.
While the client uses a cane for support, they are still able to rise from a seated position independently, so no assist is not appropriate.

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A nurse is reinforcing teaching with a client about using a cane for ambulation. Which of the following statements should the nurse make?

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Correct Answer is C

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