A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide?

"Maintain your head and neck erect when walking with crutches."

"Keep your elbows flexed at a 35° angle when using the crutches."

"Support your body weight by leaning on the crutches."

“Wash the tips of your crutches daily."

Answer and Explanation

The Correct Answer is B

A. "Maintain your head and neck erect when walking with crutches.": This is incorrect. The focus should be on posture and the use of crutches, not just the head and neck. Maintaining an erect posture is essential, but this option is too narrow and doesn’t provide full guidance on proper crutch use.

B. "Keep your elbows flexed at a 35° angle when using the crutches.": This is correct. The elbows should be slightly bent, approximately at a 30- to 35-degree angle, to ensure proper use of the crutches. This position prevents excessive strain on the shoulders and wrists while providing effective support.

C. "Support your body weight by leaning on the crutches.": This is incorrect. The crutches should not bear the entire weight of the body. Instead, the weight should be distributed through the arms and hands with the crutches supporting some of the load. Leaning on the crutches can lead to nerve damage or further injury.

D. “Wash the tips of your crutches daily.": This is incorrect. While it is important to keep crutches clean, washing the tips daily is unnecessary. It is more important to check the crutches for wear and tear and ensure the rubber tips are intact and provide proper traction.

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Correct Answer is A

Explanation

A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.

B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.

C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.

D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.

A. Apply the transdermal patch to either of the client's forearms. B. Remove the old transdermal patch before applying a new one. C. Apply the patch to a clean, hairless area of the client's skin. D. Use sterile gloves to apply and remove transdermal patches. E. Dispose of old transdermal patches in a childproof container.

Correct Answer is ["B","C","E"]

Explanation

A. "Apply the transdermal patch to either of the client's forearms" is incorrect. The nurse should avoid applying the patch to areas with excessive hair, irritation, or broken skin. Common areas include the upper torso (e.g., upper arm, chest, or back).

B. "Remove the old transdermal patch before applying a new one" is correct. To prevent overdose or accidental administration of an additional dose, the nurse should always remove the old patch before applying a new one.

C. "Apply the patch to a clean, hairless area of the client's skin" is correct. This ensures better adhesion and absorption of the medication, as hair and dirt can interfere with the patch's effectiveness.

D. "Use sterile gloves to apply and remove transdermal patches" is incorrect. Standard gloves are sufficient for applying and removing transdermal patches, as they do not need to be sterile.

E. "Dispose of old transdermal patches in a childproof container" is correct. Fentanyl patches should be disposed of properly to avoid accidental exposure or ingestion by children or pets. A childproof container ensures safe disposal.

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A nurse is reinforcing teaching with a client who has an ankle injury and requires crutches. Which of the following instructions should the nurse provide?

Nursing Test Bank

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Explanation

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Explanation

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