The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

Progresses to foot touchdown and weight bearing of affected leg.

Practices bicep and triceps isometric exercises.

Inspects crutches to ensure rubber tips are intact.

Bears body weight on the palms of hands during the crutch gait.

Answer and Explanation

The Correct Answer is A

A. Progresses to foot touchdown and weight bearing of affected leg:

This choice indicates that the client understands proper crutch walking because it involves the correct progression of weight-bearing on the affected leg while using the crutches for support. In the three-point gait crutch walking technique, the client progresses by first touching down the foot of the affected leg and then transferring weight onto that leg while stepping forward with the crutches. This behavior ensures proper balance and support during ambulation.

B. Practices bicep and triceps isometric exercises:

This choice does not directly indicate understanding of proper crutch walking. While strengthening the biceps and triceps muscles can be beneficial for overall strength and endurance, it is not a specific behavior related to proper crutch walking technique.

C. Inspects crutches to ensure rubber tips are intact:

While it is important to inspect crutches regularly to ensure they are in good condition, this behavior alone does not necessarily indicate an understanding of proper crutch walking technique. It is more related to equipment maintenance and safety rather than the actual execution of crutch walking.

D. Bears body weight on the palms of hands during the crutch gait:

This choice suggests an incorrect technique. Proper crutch walking technique involves bearing weight on the hands through the hand grips of the crutches rather than the palms. Placing excessive weight on the palms can lead to discomfort, injury, and improper weight distribution, which could hinder effective ambulation.

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Correct Answer is A

Explanation

A. When the client voided following catheter removal:

This information is crucial because it indicates the return of the client's ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.

B. Color of the urine during catheter removal:

While the color of the urine during catheter removal may provide some insight into the client's urinary condition, it is not as critical as knowing when the client voided after catheter removal to assess urinary function.

C. Time of the last dose of IV antibiotic administration:

While the timing of the last dose of IV antibiotic administration is important for managing the client's urinary tract infection, it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.

D. Intake and output reports for the previous shift:

Intake and output reports are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.

A. Places food on the unaffected side of the mouth. B. Raises the head of the bed to 60 degrees. C. Positions the head with the chin tilted slightly downward. D. Allows 30 minutes of rest before feeding.

Correct Answer is D

Explanation

A. Places food on the unaffected side of the mouth:

This is correct practice for clients at risk for aspiration. Placing food on the unaffected side helps ensure safer swallowing.

B. Raises the head of the bed to 60 degrees:

This is appropriate as it helps reduce the risk of aspiration by promoting proper positioning during feeding.

C. Positions the head with the chin tilted slightly downward:

Positioning the head with the chin tilted slightly downward (chin tuck) helps close off the airway during swallowing, further reducing the risk of aspiration. This is another appropriate technique to minimize the risk of aspiration during feeding.

D. Allows 30 minutes of rest before feeding:

This is incorrect because it’s generally important to avoid long periods of rest before feeding. The client should be well-rested, but allowing 30 minutes specifically as a rest period before feeding is not a standard practice and may not align with the client's needs or feeding protocols.

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The nurse is demonstrating three point gait crutch walking to an older adult client who broke a foot while playing soccer with the grandchildren. Which behavior Indicates that the client understands proper crutch walking?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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