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 D
Explanation
The correct answer is choice D. This type of device is useful for a client who cannot assist.
A mechanical lift is used to transfer residents who cannot support their own weight.
It does not require the client to use upper body strength, as choice A suggests.
The lower end of the sling should go under the client’s thighs, not below the calves, as choice B states.
The sides of the sling are not for the client to hold on to, but for the caregiver to attach to the hooks on the lift, as choice C implies.
Therefore, choices A, B and C are wrong because they do not reflect the proper use of a mechanical lift.
Correct Answer is C
Explanation
The correct answer is choice C. “Dangle your legs over the side of the bed.” This helps prevent orthostatic hypotension, which is a form of low blood pressure that happens when standing after sitting or lying down.
Dangling the legs over the side of the bed allows blood to flow back to the heart and increases blood pressure before standing up.
Choice A is wrong because “Perform regular isometric exercises.” Isometric exercises are muscle contractions without movement, such as squeezing a ball or clenching a fist.
These exercises do not help with orthostatic hypotension because they do not improve blood circulation or blood pressure.
Choice B is wrong because “Increase your intake of protein.” Protein intake does not affect orthostatic hypotension directly.
However, staying hydrated by drinking plenty of fluids can help prevent or manage the condition by maintaining blood volume and blood pressure.
Choice D is wrong because “Use your incentive spirometer.” An incentive spirometer is a device that helps improve lung function after surgery by encouraging deep breathing.
It does not prevent orthostatic hypotension because it does not affect blood pressure or blood flow.
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