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 C
Explanation
A: Checking the client’s skin every 8 hours is not frequent enough to prevent skin breakdown in a client with urinary incontinence. More frequent checks are necessary to identify and address any issues promptly.
B: Cleaning the client’s skin and perineum with hot water can cause skin irritation and dryness. It is better to use lukewarm water and gentle cleansers to maintain skin integrity.
C: Applying a moisture barrier ointment to the client’s skin is an effective way to prevent skin breakdown. The ointment creates a protective barrier that helps keep moisture away from the skin, reducing the risk of irritation and breakdown.
D: Requesting a prescription for the insertion of an indwelling urinary catheter is not the best first-line intervention for preventing skin breakdown. Catheters carry a risk of infection and should be used only when absolutely necessary.
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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