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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Including more cantaloupe in the diet is a good practice for a client on furosemide therapy. Cantaloupe is high in potassium, and furosemide can cause hypokalemia (low potassium levels) as it is a potent diuretic that increases urine production and the excretion of various electrolytes, including potassium. Therefore, consuming foods rich in potassium can help counteract this potential adverse effect.
Choice B reason: Checking the pulse before taking the medication is a general safety measure but does not directly relate to a specific adverse effect of furosemide. While it's important to monitor heart rate, especially in clients with heart failure, this statement does not reflect an understanding of the adverse effects related to furosemide.
Choice C reason: Trying to limit foods that contain salt is an appropriate action for a client with heart failure but is not directly related to an adverse effect of furosemide. Reducing salt intake can help manage heart failure by preventing fluid retention; however, it does not address the specific adverse effects of furosemide therapy.
Choice D reason: Checking blood pressure to ensure it doesn't get too high is important for clients with heart failure but does not indicate an understanding of the adverse effects of furosemide. Furosemide is used to reduce excess fluid in the body, which can lower blood pressure, not increase it. This statement does not reflect an understanding of furosemide's potential to cause electrolyte imbalances.
Correct Answer is A
Explanation
Choice A reason : Uric acid levels are expected to be increased in a client with acute gout. Gout is associated with hyperuricemia, where serum or plasma urate concentrations exceed 6.8 mg/dL. This elevation in uric acid can lead to the formation of monosodium urate crystals in joints, causing the characteristic painful inflammation of gout.
Choice B reason : Intrinsic factor is not related to gout. It is a protein produced by the stomach that is necessary for the absorption of vitamin B12.
Choice C reason : Chloride levels are typically not affected in acute gout and are not a specific indicator for this condition.
Choice D reason : Creatinine kinase is an enzyme found in the heart, brain, skeletal muscle, and other tissues. Elevated levels may indicate muscle damage but are not a specific marker for gout.
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