A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Hold the cane on the right side to provide support for the weaker leg

Remove the rubber tip when using the cane.

Advance the right leg and the cane together to support the weaker leg

Place the cane approximately 61 cm (24 in) in front of her feet before advancing

Answer and Explanation

The Correct Answer is A

A: The correct instruction is to hold the cane on the right side, which is the side opposite the weaker leg. This provides better support and balance for the weaker side.

B: Removing the rubber tip from the cane is not recommended. The rubber tip provides traction and stability, reducing the risk of slipping.

C: Advancing the right leg and the cane together is incorrect. The cane should move with the weaker leg (left leg in this case) to provide support during ambulation.

D: Placing the cane 61 cm (24 in) in front of the feet is too far. The cane should be placed about 15-25 cm (6-10 in) in front of the feet to provide optimal support and balance.

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Correct Answer is B

Explanation

A: Checking the client’s motor strength is not the first priority during a seizure. Ensuring the client’s safety and airway patency is more important.

B: Turning the client’s head to the side is the first action. This helps maintain an open airway and prevents aspiration of saliva or vomit.

C: Documenting the time the seizure began is important for medical records but is not the immediate priority during the seizure.

D: Loosening the clothing around the client’s waist can help with comfort but is not the first action to take during a seizure.

A. Renal dysfunction B. Pancreatic impairment C. Increased gastric motility D. Increased blood volume

Correct Answer is A

Explanation

A: Renal dysfunction is common in older adults and can lead to decreased clearance of medications from the body, increasing the risk of toxicity. Monitoring for signs of toxicity is crucial in this population.

B: Pancreatic impairment can affect digestion and insulin production but is not the primary reason for monitoring medication toxicity in older adults.

C: Increased gastric motility is not typically associated with aging. In fact, decreased gastric motility is more common and can affect drug absorption.

D: Increased blood volume is not a common physiological change in older adults. Decreased renal function and changes in body composition are more relevant factors affecting medication metabolism and excretion.

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A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is in a client’s room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

The nurse closely monitors an older adult for signs of medication toxicity. Which physiological change is the reason for the nurse’s action?

Correct Answer is A

Explanation

A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

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