A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?

Four-point alternating gait

Swing-through gait

Three-point gait

Two-point alternating gait

Answer and Explanation

The Correct Answer is C

A. Four-point alternating gait:

This gait involves a more natural and stable walking pattern. However, it requires weight-bearing on both legs, which may not be suitable for a client who can only bear weight on one leg.

B. Swing-through gait:

The swing-through gait is typically used by clients with bilateral lower extremity weakness. It involves swinging both legs through while supporting weight on the crutches. This gait is not suitable for a client who can only bear weight on one leg.

C. Three-point gait:

This gait is appropriate for a client who can only bear weight on one leg. In a three-point gait, the client uses crutches and swings or hops the non-weight-bearing leg forward, landing on the good leg. This gait provides stability and reduces weight-bearing on the affected leg.

D. Two-point alternating gait:

In a two-point alternating gait, the client advances the crutch and the opposite foot simultaneously. This gait is more energy-efficient than the four-point gait but requires weight-bearing on both legs. It is not suitable for a client who can only bear weight on one leg.

Diagram of different axillary crutch walking. | Download Scientific Diagram

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Correct Answer is B

Explanation

A. Whisper a series of words softly into one ear.

Explanation: Whispering words into one ear is not part of Weber's test. This action is more relevant to the assessment of hearing acuity and not the lateralization of sound. Weber's test focuses on the perception of sound in relation to both ears, not the ability to hear whispered words.

B. Place an activated tuning fork in the middle of the client's forehead.

Explanation: In Weber's test, a tuning fork is placed in the middle of the client's forehead. The test is designed to assess whether sound lateralizes (moves) to one ear or is heard equally in both ears. If the client perceives the sound more in one ear than the other, it may indicate a hearing imbalance or issue.

C. Deliver a series of high-pitched sounds at random intervals.

Explanation: Delivering high-pitched sounds at random intervals is not part of Weber's test. Weber's test involves a single action – placing an activated tuning fork in the middle of the client's forehead. The purpose is to determine if the client perceives the sound equally in both ears or if there is lateralization. Random intervals and high-pitched sounds are not specified components of this test.

D. Hold an activated tuning fork against the client's mastoid process.

Explanation: While holding a tuning fork against the mastoid process is part of another hearing test called the Rinne test, it is not the appropriate action for the Weber's test. The Rinne test compares air conduction (using the tuning fork near the ear) to bone conduction (using the tuning fork against the mastoid process) to evaluate hearing in each ear. In Weber's test, we are specifically interested in lateralization of sound, not comparing air and bone conduction.

Solved] In Weber's test, lateralization of sound to diseased ear

A. Assist the client with a bowel cleansing. B. Ensure the client is free of metal objects. C. Monitor the client for pain in the suprapubic region. D. Administer 240 mL. (8 oz) of oral contrast before the procedure

Correct Answer is A

Explanation

A. Assist the client with a bowel cleansing.A bowel cleansing is necessary before an intravenous pyelogram (IVP) to ensure the urinary tract is clearly visualized on the X-ray images. Residual stool or gas in the intestines can obscure the view of the kidneys, ureters, and bladder.

B.Ensure the client is free of metal objects.While ensuring the client is free of metal objects is critical for procedures involving magnetic resonance imaging (MRI) or X-rays of the skeletal system, it is not specifically required for an IVP.

C.Monitor the client for pain in the suprapubic region.Monitoring for suprapubic pain is more relevant after procedures such as catheterization or bladder studies, or in cases of suspected urinary retention or infection.

D.Administer 240 mL (8 oz) of oral contrast before the procedure.An IVP involves injecting contrast dye intravenously, not orally. Oral contrast is typically used for gastrointestinal studies, such as a CT scan of the abdomen or barium swallow.

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A nurse is teaching a client who can only bear weight on one leg how to ambulate using crutches. Which of the following crutch gaits should the nurse plan to instruct the client to use?

Nursing Test Bank

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