A nurse is reinforcing teaching with a client who has left-leg weakness and is learning to use a walker. Which of the following instructions should the nurse include in the teaching?

"Maintain your arms in a slightly flexed position when using the walker."

"Move your right leg forward as you advance the walker."

"Support yourself with the walker when climbing stairs."

"Keep your eyes on your feet when ambulating with the walker."

Answer and Explanation

The Correct Answer is A

A. "Maintain your arms in a slightly flexed position when using the walker.": The walker should be adjusted so the client's elbows are flexed at approximately 20° to 30°. This allows the client to bear weight through their arms effectively.

B. "Move your right leg forward as you advance the walker.": The walker should be advanced first, followed by the affected (weak) leg, then the stronger leg.

C. "Support yourself with the walker when climbing stairs.": Walkers are generally unsafe for use on stairs; a client should use a handrail and a cane or crutches if stairs are necessary.

D. "Keep your eyes on your feet when ambulating with the walker.": Clients should look forward to maintain balance and avoid obstacles; looking down increases the risk of falls.

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

Explanation

A. Telephone number: A telephone number is a valid and unique personal identifier according to Joint Commission standards.

B. Diagnosis: Multiple clients may have the same diagnosis (e.g., "Pneumonia").

C. Date of birth: This is a standard, universally accepted unique identifier.

D. Room number: Room numbers are not person-specific and can change frequently.

E. Identification bracelet: The ID band contains the client's name and a unique medical record number, making it a primary source for verification.

A. Add liquid to foods to thin consistency. B. Tilt the client's head slightly backward. C. Encourage socialization with others during meals. D. Provide mouth care before the client eats.

Correct Answer is D

Explanation

A. Add liquid to foods to thin consistency.: Thin liquids are actually the most difficult to swallow and increase the risk of aspiration. Foods should be thickened to a "nectar" or "honey" consistency as prescribed.

B. Tilt the client's head slightly backward.: This opens the airway. For safe swallowing, the client should use the "chin-tuck" method (tilting the head forward/down) to help close the trachea and open the esophagus.

C. Encourage socialization with others during meals.: Clients with dysphagia should focus entirely on chewing and swallowing to prevent aspiration; talking while eating increases risk.

D. Provide mouth care before the client eats.: Oral hygiene before meals stimulates the appetite and removes bacteria from the mouth. If a client does aspirate, they are less likely to develop pneumonia if their oral cavity is clean.

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A nurse is reinforcing teaching with a client who has left-leg weakness and is learning to use a walker. Which of the following instructions should the nurse include in the teaching?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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