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 D
Explanation
Choice A reason:A monthly calendar is often too complex and overwhelming for a client with Alzheimer’s. A single-day calendar or a daily schedule that can be marked off is much more effective for orientation.
Choice B reason: Providing plenty of stimulation can be overwhelming for clients with Alzheimer's disease. A calm and predictable environment is usually more beneficial.
Choice C reason: Keeping the room dark at night can promote sleep, but it is not the only consideration. A nightlight or low-level lighting can prevent falls if the client needs to get up during the night.
Choice D reason:When caring for a client with Alzheimer’s disease, the goal of nursing intervention is to maintain a safe, predictable environment that minimizes confusion and anxiety while maximizing the client's remaining functional abilities.
Correct Answer is D
Explanation
Choice A reason: Gurgling bowel sounds every 10 seconds are considered normal, as normoactive bowel sounds range from 5 to 30 sounds per minute. This finding indicates regular gastrointestinal activity and is not typically a cause for concern.
Choice B reason: A centrally located umbilical protrusion can be a normal finding, especially if it has been present since birth and is not associated with any other symptoms. However, if new or associated with pain or other symptoms, it could indicate a hernia or other pathology.
Choice C reason: Abdominal distention during breathing can be a normal finding, as the abdomen may distend slightly during deep breathing due to the movement of the diaphragm. However, if the distention is pronounced or associated with other symptoms, it may warrant further investigation.
Choice D reason: Rebound tenderness with palpation is a sign of peritoneal irritation and can be an indication of conditions such as appendicitis, which is a surgical emergency. This finding should be considered a priority as it may require immediate intervention.
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