A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
The client moves the cane 2 feet ahead.
The client holds the cane with their right hand.
The client takes a step with their left foot first.
The client advances the weaker (left) leg forward to the cane.
The Correct Answer is D
Choice A reason: Moving the cane 2 feet ahead is too far and can cause imbalance or a fall. The cane should be moved a short distance ahead, about the length of one natural step.
Choice B reason: Holding the cane with the right hand is correct for someone with left-sided weakness. The cane should be used on the stronger side of the body to provide support for the weaker side.
Choice C reason : Taking a step with the left foot first is not correct because the weaker leg should be advanced to the cane to ensure stability and support when moving.
Choice D reason: Advancing the weaker leg forward to the cane is correct. The cane provides support for the weaker leg, helping to maintain balance as the client walks.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Pressing down on the orbital area of the eye, known as the oculocephalic reflex or 'doll's eye' maneuver, is a method used to assess brainstem function in an unresponsive patient. However, this should be done with caution and is generally avoided if there is a suspicion of a neck injury or increased intracranial pressure.
Choice B reason: Pinching the trapezius muscle is a common method to elicit a response to painful stimuli. It is considered a less invasive and safer initial approach to assess the patient's response to pain without causing harm.
Choice C reason: Using a 25-gauge needle to elicit a response is not a standard practice and can be harmful. It poses a risk of skin puncture and infection, and it is not an appropriate method for assessing a patient's level of consciousness.
Choice D reason: Eliciting a reflex with a reflex hammer is used to assess the deep tendon reflexes, which can provide information about the integrity of the nervous system. However, it is not typically used as a method to elicit a response to painful stimuli in an unresponsive patient.
Correct Answer is D
Explanation
Choice A reason: Advising the client to avoid carbohydrates after exercise is not appropriate. Carbohydrates are necessary to replenish glycogen stores after exercise, and individuals with diabetes need to monitor their blood sugar levels to manage carbohydrate intake accordingly.
Choice B reason: Saying it is normal to feel exhausted after a morning run does not address the client's symptoms of diaphoresis, increased heart rate, and palpitations, which could be signs of hypoglycemia, a common risk for individuals with type 1 diabetes after exercise.
Choice C reason: While it's true that exercise can become easier with routine, this statement does not address the client's immediate concerns about their symptoms following exercise.
Choice D reason: Asking if the client decreased their insulin intake before exercising is an appropriate response. Individuals with type 1 diabetes need to adjust their insulin dosage to account for physical activity, which can significantly lower blood glucose levels.
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