A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make?
"Advance the cane 12 inches forward when walking."
"Keep the cane at the same level as the affected leg when climbing stairs."
"Hold the cane on the side of your affected leg when walking."
"Move your unaffected leg before your affected leg when walking."
The Correct Answer is D
A. "Advance the cane 12 inches forward when walking." Advancing the cane 12 inches forward is not practical; the cane should be moved in a manner that aligns with the client's steps for better balance and support. The movement of the cane should be synchronized with the client's stride rather than a fixed distance.
B. "Keep the cane at the same level as the affected leg when climbing stairs." When climbing stairs, the cane should be held on the side of the unaffected leg to provide optimal support and balance. Keeping the cane level with the affected leg is incorrect and does not provide adequate support.
C. "Hold the cane on the side of your affected leg when walking." The cane should be held on the side opposite the affected leg to provide better stability and support. Holding the cane on the affected side would not offer the necessary support for effective ambulation.
D. "Move your unaffected leg before your affected leg when walking." This is the correct technique as it ensures better balance and stability. Moving the unaffected leg first while using the cane allows for a more secure and coordinated gait, reducing the risk of falls.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Acute Pain: This represents the diagnostic label in the nursing diagnosis but does not include specific symptoms or evidence related to the client's condition.
B. Natural swelling: This is not relevant to the symptoms described in the scenario and does not represent the specific signs of the client's condition.
C. Guarding and restricted movement: This describes the specific observable signs and symptoms reported by the patient, which are part of the "Signs and Symptoms" component (S) in the PES format.
D. Related to incisional trauma: This part of the diagnosis describes the cause or contributing factor of the pain, which is the "Etiology" component, not the "Signs and Symptoms."
Correct Answer is B
Explanation
A. Review the steps for checking a radial pulse with the client: This method involves cognitive learning, as it focuses on understanding and recalling information rather than performing a physical skill.
B. Observe the client checking their radial pulse: This method involves the psychomotor domain because it focuses on the client's ability to perform the physical task of checking their pulse. The nurse can assess the client’s skill in action.
C. Tell the client the expected reference range of their radial pulse: This approach falls under cognitive learning, focusing on providing factual information rather than hands-on practice.
D. Discuss the purpose of checking the radial pulse with the client: This is also a cognitive learning method, as it involves understanding the reasons behind the procedure rather than the physical execution of it.
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