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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Continuous output from the stoma is expected in patients with an ileostomy. The stoma continuously produces waste, and this is a normal finding.
B: The presence of blood in the stool is an abnormal finding and should be reported immediately. It could indicate bleeding within the gastrointestinal tract, which requires prompt medical evaluation and intervention.
C: Malodorous stool is common with an ileostomy and is not typically a cause for immediate concern. However, if the odor is unusually strong or different, it may warrant further investigation.
D: Liquid consistency of stool is normal for an ileostomy, as the large intestine, which absorbs water, is bypassed. This is not an immediate concern unless there are other symptoms present.
Correct Answer is C
Explanation
A: Clostridium difficile infection typically develops after prolonged antibiotic use and is not the most likely cause of diarrhea immediately after starting enteral feeding.
B: Antibiotic therapy can cause diarrhea, but it is not the most likely cause in this scenario where the diarrhea started soon after beginning enteral feeding.
C: Formula intolerance is the most likely cause of diarrhea shortly after starting enteral feeding. The patient’s digestive system may not tolerate the formula well, leading to diarrhea.
D: Bacterial contamination is a possible cause but is less likely to cause immediate diarrhea after starting enteral feeding compared to formula intolerance. Proper handling and preparation of the formula should minimize this risk.
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