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. Heart rhythm: This is correct. Hypothermia, indicated by a body temperature of 32.5°C (90.5°F), can affect the cardiovascular system, potentially causing arrhythmias or even cardiac arrest. Monitoring heart rhythm is critical because of the risk of life-threatening cardiac complications associated with severe hypothermia.

B. Urinary output: While urinary output may decrease in hypothermic conditions due to vasoconstriction, it is not the priority. Cardiac function takes precedence, as severe hypothermia can lead to fatal arrhythmias.

C. Pain sensation: Although decreased pain sensation can occur in hypothermia, it is less urgent to monitor compared to the potential for life-threatening arrhythmias or cardiac arrest.

D. Muscle strength: While hypothermia can impair muscle strength, it is not the priority compared to monitoring for cardiac irregularities, which can be fatal if left unchecked.

A. Measure the duration of the seizure. B. Lower the side rails of the bed when the seizure begins. C. Insert an oral airway into the client's mouth. D. Restrain the client's arms and legs to prevent injury.

Correct Answer is A

Explanation

A. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention.

B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed.

C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended.

D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).

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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

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5°F). Which of the following data is the priority for the nurse to monitor?

Correct Answer is A

Explanation

A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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