A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?
When walking, move your left foot forward first.
Keep your elbow straight when you hold the cane.
Move the cane forward 18 inches with each step.
Hold the cane with your left hand.
The Correct Answer is A
A reason:
When walking, moving the left foot forward first is correct. For clients with left-sided weakness, the cane should be used to provide support for the weak side. Moving the left foot first while using the cane helps maintain balance and stability.
B reason:
Keeping the elbow straight when holding the cane is incorrect. The elbow should be slightly bent when holding the cane to allow for better control and shock absorption, reducing strain on the arm.
C reason:
Moving the cane forward 18 inches with each step is incorrect. The cane should be moved a comfortable distance forward, typically about 6 to 12 inches, to maintain stability and support without overreaching.
D reason:
Holding the cane with the left hand is incorrect. For left-sided weakness, the cane should be held in the right hand to provide support and balance on the opposite side of the weakness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A reason: I will place an area rug at the entry of my bathroom. Placing an area rug at the entry of the bathroom can be a tripping hazard, especially for a client with a history of falls. Rugs can slip or bunch up, increasing the risk of falls, making this statement incorrect for ensuring home safety.
B reason: I will keep the fluorescent ceiling light on in my room at night. Keeping a light on at night can help prevent falls by improving visibility, especially during trips to the bathroom. However, it is not as directly related to fall prevention as other measures like using assistive devices or securing trip hazards. This statement is less focused on the primary prevention strategy.
C reason: I will place a bath seat in my shower to use when I bathe. Using a bath seat is an effective fall prevention strategy in the shower, where surfaces are often slippery. A bath seat provides stability and support, reducing the risk of falls while bathing. This indicates a clear understanding of home safety measures for fall prevention.
D reason: I will keep my walker at the end of my bed. While keeping a walker within reach is important, placing it at the end of the bed may not be the most convenient or safest location. Ideally, the walker should be easily accessible from where the client gets in and out of bed. This statement does not show the best understanding of optimal safety practices.
Correct Answer is ["A","B","D","E"]
Explanation
A reason:
More difficulty seeing due to a greater sensitivity to glare is a common change with aging. The lens of the eye becomes less flexible and more prone to glare.
B reason:
A decreased cough reflex is typical in older adults, making them more susceptible to respiratory infections and complications.
C reason:
Decreased systolic blood pressure is not a common change with aging. Instead, systolic blood pressure often increases due to decreased elasticity of blood vessels.
D reason:
Decreased bladder capacity is a normal part of aging, leading to increased frequency of urination and sometimes incontinence.
E reason:
Dehydration of intervertebral discs occurs with aging, leading to reduced height and potential for back pain and decreased mobility.
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