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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Use soap and water to clean the client's perineum: Correct. Using soap and water is the standard method for cleaning the perineum to ensure it is effectively cleaned while maintaining hygiene.
B. Use the same section of washcloth for each area cleaned: Incorrect. To prevent cross-contamination, the nurse should use a clean section of the washcloth or a new washcloth for each area cleaned.
C. Allow the client's perineum to air dry: Incorrect. The perineum should be gently patted dry with a clean towel to prevent irritation and ensure proper drying.
D. Start at the client's rectum and clean to the client's perineum: Incorrect. The proper technique is to clean from the perineum to the rectum to prevent the spread of bacteria from the rectal area to the vaginal area.

A. Acute Pain B. Natural swelling C. Guarding and restricted movement D. Related to incisional trauma

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."

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A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make?

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