When instructing a client on the proper use of a cane, which step is essential to ensure stability and safety?

Use the cane on the same side as the injured or weaker leg.

Move the cane and the stronger leg forward together.

Adjust the cane height so the handle is above the waist level.

Hold the cane on the side opposite the injured or weaker leg.

Answer and Explanation

The Correct Answer is D

A. Use the cane on the same side as the injured or weaker leg: This approach is incorrect. The cane should be used on the opposite side of the weaker leg to provide better support and balance during ambulation. Using the cane on the same side would not provide adequate stability and could increase the risk of falling.

B. Move the cane and the stronger leg forward together: This step is not recommended. The proper technique involves moving the cane first, followed by the weaker leg, and then bringing the stronger leg forward. This sequence helps maintain stability and balance while walking.

C. Adjust the cane height so the handle is above the waist level: The cane should be adjusted so that the handle is at the level of the wrist when the client is standing upright, which allows for proper elbow flexion while using the cane. If the handle is too high, it can lead to poor posture and increased strain.

D. Hold the cane on the side opposite the injured or weaker leg: This is the essential step for ensuring stability and safety when using a cane. By holding the cane on the opposite side, the client can use the cane for support while stepping forward with the weaker leg, enhancing balance and reducing the risk of falls. This technique allows for better weight distribution and improved mobility.

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Correct Answer is A

Explanation

A. 18: A score of 18 on the Braden Scale indicates that the patient is at low risk for skin breakdown. The Braden Scale scores range from 6 to 23, with lower scores indicating higher risk. A score of 18 or above suggests that the implemented interventions have effectively reduced the risk of skin impairment, making this the best sign that the risk for skin breakdown has been removed.

B. 13: A score of 13 indicates moderate risk for skin breakdown. While this is an improvement from a score of 15, it still shows that the patient remains at risk and requires ongoing monitoring and intervention.

C. 23: A score of 23 indicates very low risk for skin breakdown; however, it is not a feasible score for patients who were initially assessed at 15. Achieving this score would likely suggest an unrealistic improvement in the patient's condition based solely on nursing interventions.

D. 12: A score of 12 indicates a high risk for skin breakdown. This score signifies that the risk has not been effectively addressed, and the patient continues to be vulnerable to skin impairment.

A. Trochanter roll B. Sheepskin heel pad C. Footboard D. Abduction pillow

Correct Answer is C

Explanation

A. Trochanter roll: A trochanter roll is used to prevent external rotation of the hips in clients who are immobilized, but it does not specifically address plantar flexion contractures of the feet.

B. Sheepskin heel pad: While a sheepskin heel pad can help prevent pressure ulcers on the heels, it does not actively prevent plantar flexion contractures. It is more focused on protecting the skin from friction and pressure.

C. Footboard: A footboard is the most appropriate device to prevent plantar flexion contractures. It provides support to the feet and helps keep them in a neutral position, reducing the risk of contractures developing in the calf muscles and Achilles tendon due to prolonged immobility.

D. Abduction pillow: An abduction pillow is used primarily to maintain the position of the legs after hip surgery and to prevent hip dislocation. It does not specifically prevent plantar flexion contractures.

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When instructing a client on the proper use of a cane, which step is essential to ensure stability and safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

Correct Answer is A

Explanation

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Correct Answer is C

Explanation

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