A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait.
Which of the following instructions should the nurse include?
Bear weight on the unaffected leg.
Keep the crutches at the level of the axillae.
Stand with the crutch tips against the feet.
Hold the arms straight when walking.
The Correct Answer is A
This gait pattern is used when one of the lower extremities is unable to fully bear weight due to fracture, amputation, joint replacement etc12 The client should advance both crutches and the affected leg as one unit, and then bring the unaffected leg forward to the crutches as the second unit
Choice B is wrong because keeping the crutches at the level of the axillae can cause nerve damage and reduce circulation.
The crutches should be positioned with 2 fingers of distance between the axilla and the axilla pad with the elbow flexed between 20-30 degrees
Choice C is wrong because standing with the crutch tips against the feet can cause instability and increase the risk of falling.
The crutch tips should be placed about 15 cm (6 inches) in front of and 15 cm to the side of each foot
Choice D is wrong because holding the arms straight when walking can cause fatigue and strain on the shoulders and wrists.
The client should keep a slight bend in the elbows when walking with crutches
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This action will help the client hear the nurse better by reducing competing sounds.
The nurse should also face the client when speaking, use short phrases, and communicate using paper and pen if needed.
Choice A is wrong because using short phrases alone is not enough to promote communication with a client who has hearing loss.
The nurse should also use other strategies such as decreasing background noise and facing the client when speaking.
Choice C is wrong because speaking in a loud voice can distort the sound and make it harder for the client to understand.
The nurse should speak clearly, slowly, and distinctly, but not shout.
Choice D is wrong because talking at a rapid rate can make it difficult for the client to follow the conversation.
The nurse should speak at a normal pace and pause between sentences.
Correct Answer is D
Explanation
The correct answer is choice D. Unequal height of the shoulders.
This is because scoliosis is a condition characterized by sideways curvature of the spine that can cause asymmetry of the shoulders, shoulder blades, and hips.
A scoliosis screening is a test that checks for this asymmetry by having the child bend forward from the waist and looking for any prominence of the rib cage or the spine.
Choice A is wrong because expansion of the upper intercostal spaces is not a sign of scoliosis, but rather a sign of hyperinflation of the lungs due to conditions such as asthma or emphysema.
Choice B is wrong because increased convex curve of the cervical spine is not a sign of scoliosis, but rather a sign of kyphosis, which is an excessive outward curvature of the upper spine.
Choice C is wrong because increased concave curve of the thoracic spine is not a sign of scoliosis, but rather a sign of lordosis, which is an excessive inward curvature of the lower spine.
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