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A nurse assists a client with left-sided weakness to walk with a cane. What is the correct order of steps for gait training with a cane?
- A. 3,5,1,2,4,6
- B. 3,5,2,4,1,6
- C. 3,5,1,2,4,6
- D. 3,5,4,1,2,6
Correct Answer: C
Rationale: The correct sequence for gait training with a cane for a client with left-sided weakness is: (3) Guide the client to a standing position, (5) Place the cane in the client's right hand (strong side), (1) Position for left and around the client's waist for support, (2) Move the cane and left leg forward at the same time, (4) Move the right leg and step forward, (6) Check balance and repeat the sequence. This ensures safe and effective ambulation.
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A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this client's teaching prior to beginning rehabilitation activities?
- A. Use analgesic before and after activity, even if you are not experiencing pain.
- B. Let me know if you start to experience shortness of breath, chest pain, or fatigue.
- C. Use physical therapy before and after activity.
- D. If you experience knee pain, ask the physical therapist to reschedule your therapy.
Correct Answer: B
Rationale: Participation in exercise may increase myocardial oxygen demand beyond the ability of the coronary circulation to deliver enough oxygen to meet the increased need. The nurse must instruct the client to report symptoms such as shortness of breath, chest pain, or fatigue, which indicate that the heart is not receiving adequate oxygen during activity. Using analgesics prophylactically is not necessary unless prescribed. Physical therapy is a structured program, not something used before and after activity. Rescheduling therapy due to knee pain may delay recovery, and pain should be managed appropriately instead.
A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity violence?
- A. Vital signs before, during, and after activity
- B. Body image and self-care abilities
- C. Vital signs use and self-care device devices
- D. Clients electrocardiography readings
Correct Answer: A
Rationale: To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase more than 20 mmHg, or the client may experience symptoms indicating intolerance. Body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices are important when planning rehabilitation activities but do not provide essential information about activity tolerance. Electrocardiography is not typically used to monitor clients in a rehabilitation setting for activity tolerance.
A nurse teaches a client about performing intermittent self-catheterization. The client states, 'I am not sure if I will be able to afford these catheters.' How should the nurse respond?
- A. You may qualify for financial assistance; let's discuss options with a social worker.
- B. Even though it is expensive, the cost of taking care of urinary tract infections would be even higher.
- C. Instead of purchasing new catheters, you can boil the catheters and reuse them up to 10 times each.
- D. You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.
Correct Answer: D
Rationale: Using clean technique for intermittent self-catheterization at home is sufficient to prevent urinary tract infections and reduces costs by allowing catheter reuse after proper cleaning. Referring to a social worker for financial concerns is appropriate but not the most direct response to the client's concern. Boiling catheters is not a recommended practice, and emphasizing the cost of infections may cause anxiety without addressing the issue.
A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
- A. Passive range of motion
- B. Active range of motion
- C. Resistive range of motion
- D. Aerobic exercise
Correct Answer: B
Rationale: Active range of motion exercises promote strength, range of motion, and independence with activities of daily living, making them appropriate for a client with generalized weakness. Passive range of motion is suitable for clients unable to move independently, resistive range of motion may be too strenuous, and aerobic exercise may not directly address the client's need for improved daily function.
A rehabilitation nurse is caring for an older adult client who states, 'I tire easily.' How should the nurse respond? (Select all that apply.)
- A. Make a schedule for completing major tasks in the morning.
- B. Use a cart to push your belongings instead of carrying them.
- C. Your family should hire someone who can assist you with daily chores.
- D. Plan to gather all of the supplies needed for a chore prior to starting the activity.
- E. Try to break large activities into smaller parts to allow rest periods between activities.
Correct Answer: B,D,E
Rationale: Using a cart reduces energy expenditure compared to carrying items. Gathering supplies before starting a chore minimizes unnecessary steps. Breaking large activities into smaller parts allows rest periods, helping manage fatigue. Scheduling major tasks in the morning is a good strategy but not listed as an option. Hiring assistance is not ideal as it does not promote independence.