A nurse is reinforcing teaching with a client who has multiple sclerosis and is learning how to use the four- point alternate gait with crutches. Identify the order of the steps the nurse should give to the client. (Move the steps of the four-point alternate gait into the box on the right placing them in the selected order of performance. Use all the steps.)

Move the right crutch about 10 to 15 cm (4 to 6 in).

Move the left foot forward.

Move the left crutch forward.

Move the right foot forward.

Answer and Explanation

The Correct Answer is A,B,C,D

The order of the steps for the four-point alternate gait with crutches is as follows: move the right crutch about 10 to 15 cm (4 to 6 in), move the left foot forward, move the left crutch forward, and move the right foot forward. This gait patern provides maximum stability and support for the client by keeping three points of contact on the ground at all times.

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Correct Answer is D

Explanation

a. Auscultation of lungs revealing wheezing is not related to venous return in the aﬀected arm. Wheezing is
a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.

b.A bounding distal pulse indicates strong arterial blood flow, which is not a sign of impaired venous return. Impaired venous return would more likely result in a weak or absent pulse.

c. Fever could indicate infection but is not specific to impaired venous return. It's a systemic sign that may or may not be related to the cast or the fracture.

d. Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments. This requires immediate medical attention to prevent permanent damage.

A. Raise the head of the bed. B. Check the client for a fecal impaction. C. Check the client's bladder for distention. D. Ensure the room temperature is warm.

Correct Answer is A

Explanation

If a nurse is caring for a client who has a spinal cord injury and suspects that the client has autonomic dysreﬂexia, the first action the nurse should take is to raise the head of the bed. This can help to lower the client's blood pressure and reduce the risk of complications such as stroke.

b. Checking the client for a fecal impaction is an important step in identifying and treating the underlying cause of autonomic dysreﬂexia, but it is not the first action the nurse should take.
c. Checking the client's bladder for distention is an important step in identifying and treating the underlying cause of autonomic dysreﬂexia, but it is not the first action the nurse should take.
d. Ensuring that the room temperature is warm is not a priority intervention for a client who has autonomic dysreﬂexia.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has a short arm cast for a fractured wrist. Which of the following findings indicates impaired venous return in the aﬀected arm?

Correct Answer is D

Explanation

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse at a community health clinic is caring for a client who reports a headache and stiﬀ neck. Which of the following actions should the nurse perform first?

While collecting data from a client who has a cast on his right leg, a nurse locates an area on the cast that feels warm to the touch. Which of the following findings should the nurse identify as a complication to the client's condition?

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

A nurse is reinforcing teaching about Russell's traction with a newly licensed nurse. Which of the following statements should the nurse make?

A nurse in an urgent care centre is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

A nurse is reinforcing teaching with a client who has an ankle sprain. Which of the following instructions should the nurse include?

A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?