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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A reason:

Massaging the skin over bony prominences is incorrect. This can cause damage to underlying tissues, particularly in areas at high risk for pressure ulcers.

B reason:

Using a transfer device to lift the client up in bed is correct. This helps to reduce friction and shear, which can contribute to skin breakdown and pressure ulcer development.

C reason:

Elevating the head of the bed no more than 45 degrees can help, but it is not as directly related to maintaining skin integrity as using a transfer device. Elevating the head too much can increase pressure on the sacrum and heels.

D reason:

Applying cornstarch is not recommended as it can promote fungal growth and irritation. Proper moisture management with barrier creams is more effective for keeping skin dry and intact.

A. Blood pressure increases with age. B. Blood pressure decreases after eating food. C. Blood pressure is usually highest on arising in the morning. D. Blood pressure tends to be higher in smokers. E. Hormones can affect blood pressure as seen in women after menopause

Correct Answer is ["A","C","D","E"]

Explanation

A reason:

Blood pressure increases with age because blood vessels naturally become less flexible and more resistant to blood flow as we age. This resistance can cause an increase in blood pressure. Additionally, lifestyle factors and accumulation of health issues over time contribute to higher blood pressure in older adults.

B reason:

Blood pressure does not typically decrease after eating food. Instead, it may temporarily increase due to the body’s metabolic response to digestion and absorption of nutrients. Some individuals may experience postprandial hypotension, but this is not a common occurrence.

C reason:

Blood pressure is usually highest on arising in the morning due to the body's natural circadian rhythm. The release of certain hormones like cortisol and adrenaline upon waking can cause an increase in blood pressure. This phenomenon is known as the "morning surge."

D reason:

Blood pressure tends to be higher in smokers because nicotine and other chemicals in cigarettes cause vasoconstriction, which increases blood pressure. Chronic smoking can also lead to long-term damage to the cardiovascular system, further elevating blood pressure.

E reason:

Hormones can affect blood pressure, especially in women after menopause. The decline in estrogen levels can lead to increased blood pressure due to changes in vascular health and metabolism. Hormonal fluctuations throughout a woman's life can also influence blood pressure.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is B

Explanation

The nurse instructor is teaching student nurses about the factors that may affect a patient's blood pressure. Which statements accurately describe these factors? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

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