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A nurse is instructing a patient recovering from a stroke on proper use of a cane. What information will the nurse include in the teaching plan?
- A. Support weight on the stronger leg and cane and advance weaker foot forward.
- B. Hold the cane in the same hand of the leg with the most severe deficit.
- C. Stand with as much weight distributed on the cane as possible.
- D. Avoid using the cane to rise from a sitting position, as this is unsafe.
Correct Answer: A
Rationale: The proper procedure for using a cane is to (1) stand with weight distributed evenly between the feet and cane; (2) support weight on the stronger leg and the cane and advance the weaker foot forward, parallel with the cane; (3) support weight on the weaker leg and cane and advance the stronger leg forward ahead of the cane; (4) move the weaker leg forward until even with the stronger leg and advance the cane again as in step 2. The patient should keep the cane within easy reach and use it for support to rise safely from a sitting position.
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When a patient is being moved or ambulated and starts to fall, the nurse should take which actions in which order?
- A. Place their feet wide apart with one foot in front
- B. Rock their pelvis out toward the side of the patient
- C. Grasp the gait belt
- D. Support the patient by pulling the patient's weight backward against their body
- E. Gently slide the patient down their body toward the floor while protecting the patient's head
- F. Remain with the patient while calling for help
Correct Answer: C,F,A,E,D,B
Rationale: When a patient is being moved or ambulated and starts to fall, the nurse places their feet wide apart with one foot in front, rocks their pelvis out toward the side of the patient, grasps the gait belt, supports the patient by pulling the patient's weight backward against their body, gently slides the patient down their body toward the floor while protecting the patient's head, and remains with the patient while calling for help.
A nurse is teaching a patient with weak dorsiflexion how to prevent foot drop. Which instruction should the nurse include?
- A. Maintain the supine position with supination on the feet.
- B. Ask the family to bring in high-top sneakers to maintain foot dorsiflexion.
- C. Encourage hyperextension of the feet with adapdive devices or splints.
- D. Use pillows to keep the feet in the abducted position.
Correct Answer: B
Rationale: To prevent foot drop, the nurse should support the feet in dorsiflexion using a footboard and/or high-top sneakers for further support. Supination involves lying patients on their back or facing a body part upward, and hyperextension is a state of exaggerated extension. Abduction involves lateral movement of a body part away from the midline of the body. These positions do not prevent foot drop.
A nurse working in a long-term care facility uses proper principles of ergonomics when moving and transferring patients to avoid back injury. Which action should be the focus of these preventive measures?
- A. Carefully assessing the patient care environment
- B. Using two nurses to lift a patient who cannot assist
- C. Wearing a back belt to perform routine duties
- D. Properly documenting the patient lift
Correct Answer: A
Rationale: Preventive measures should focus on careful assessment of the patient care environment so that patients can be moved safely and effectively. Using lifting teams and assistive patient handling equipment rather than two nurses to lift increases safety. The use of a back belt does not prevent back injury. The methods used for safe patient handling and mobility should be documented but are not the primary focus of interventions related to injury prevention.
By what age is head control usually achieved in infants?
- A. 5 months
- B. 6 to 9 months
- C. 15 months
- D. 2 years
Correct Answer: A
Rationale: By 5 months, head control is usually achieved. An infant usually rolls over by 6 to 9 months. By 15 months, most toddlers can walk unassisted. By 2 years, most toddlers can jump.
Two nurses are repositioning a patient and pulling the patient up in bed. Which of these steps is most appropriate to prevent injury to the nurses?
- A. Telling the patient to cross their arms and legs
- B. Pulling the patient from underneath the axilla toward the top of the bed
- C. Avoiding using a draw sheet to lift or reposition the patient
- D. Ensuring the bed is at the level of the nurses' hips
- E. Facing the head of the bed and rocking in synchrony
Correct Answer: D
Rationale: The nurses should face the direction the patient will move and rock in synchrony prior to moving the patient in that direction. A lifting or repositioning sheet or device is used to decrease friction and facilitate movement. While the patient can cross their arms, they can also be instructed to press their feet into the mattress to assist movement. The bed should be at the level of the nurses' elbows, not hips, to maintain proper ergonomics and prevent injury.