A nurse is teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching?

A. The client may have difficulty voiding despite being taken to the bathroom, especially if there is an underlying issue such as urinary retention or an obstruction. Therefore, this step is usually taken after assessing the situation further.
B. Inserting a straight catheter is an invasive procedure that should not be the initial action. It is typically done after other non-invasive measures have been taken to evaluate the reason for the lack of voiding. Straight catheterization can be considered if other methods do not resolve the issue or if there is a clear indication of urinary retention that needs immediate intervention.
C. Performing a bladder scan is the appropriate first step. A bladder scan, or portable ultrasound, helps assess the amount of urine in the bladder and determines if the client is retaining urine. This non- invasive procedure can provide valuable information about the presence of urinary retention, which guides further intervention.
D. Increasing fluid intake might be appropriate if the client is dehydrated or has not been drinking enough fluids. However, this step is not the first action to take if the client has not voided for 8 hours. The priority is to determine if there is a physiological issue, such as urinary retention, before increasing fluids.

A. While holding the client’s arm might seem like a supportive action, it is not the most effective method to prevent a fall. If a client begins to fall, holding their arm could result in injury to either the client or the nurse, as it does not provide adequate control to prevent the fall. Instead, more proactive measures should be taken to safely manage the situation.
B. Assuming a narrow base of support (standing with feet close together) is actually less stable and can increase the risk of falling. To effectively prevent or manage a fall, the nurse should assume a wide base of support (feet apart) to enhance stability and balance.
C. If a fall is imminent and cannot be prevented, the best approach is to safely lower the client to the floor to minimize the risk of injury. The nurse should support the client’s body as they go down, guiding them gently to the floor to avoid a sudden impact. This technique helps reduce the potential for serious injuries such as fractures or head trauma.
D. Leaning the client toward the wall might provide temporary support but does not fully address the risk of a fall. It may also place the client in an awkward or unsafe position. The best approach is to take more direct action to prevent the fall or safely lower the client if the fall is unavoidable.