Nokea
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
- A. Hold the cane on the right side
- B. Keep 2 points of support on the floor
- C. Place the cane 15 inches in front of the feet before advancing
- D. After advancing the cane, move the weaker leg forward
- E. Advance the stronger leg so that it aligns evenly with the cane
Correct Answer: A, B, D
Rationale: Correct Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.
You may also like to solve these questions
A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.
- A. Increase in incisional pain
- B. Fever & chills
- C. Reddened wound edges
- D. Increase in serosanguineous drainage
- E. Decrease in thirst
Correct Answer: A, B, C
Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include: A) Increase in incisional pain: Infection can cause localized pain. B) Fever & chills: Systemic signs of infection. C) Reddened wound edges: Classic sign of wound infection. Incorrect choices: D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.
A nurse is assessing the pain level of a client who has come to the ER reporting severe abdominal pain. The nurse asks the client whether he has nausea & has been vomiting. The nurse is assessing which of the following?
- A. Presence of associated symptoms
- B. Location of the pain
- C. Pain quality
- D. Aggravating & relieving factors
Correct Answer: A
Rationale: The correct answer is A: Presence of associated symptoms. By asking about nausea and vomiting, the nurse is assessing for other symptoms that may accompany the abdominal pain, providing crucial information for a comprehensive assessment. This helps in identifying potential causes, such as gastrointestinal issues. Other choices are incorrect because B: Location of the pain, C: Pain quality, and D: Aggravating & relieving factors focus solely on the characteristics of pain itself and not on associated symptoms.
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. "The roommate is up independently"
- B. The client ambulates w/his slippers on over his antiembolic stockings
- C. The client uses a front-wheeled walker when ambulating
- D. The client had pain medication 30 min ago
- E. The client is allergic to codeine
Correct Answer: B, C, D
Rationale: Correct Answer: B, C, D
Rationale:
- Option B: The client should not wear slippers over antiembolic stockings as it can increase the risk of slipping or falling.
- Option C: Knowing that the client uses a front-wheeled walker is crucial for safe ambulation post-knee arthroplasty.
- Option D: Advising on the timing of pain medication helps ensure the client is comfortable during ambulation.
Summary:
- Option A is incorrect because the roommate's ambulation status is irrelevant to the client's care.
- Option E is incorrect as the client's allergy to codeine does not directly impact safe ambulation post-knee arthroplasty.
A home health nurse is discussing the dangers of carbon monoxide poisoning w/a client. Which of the following information should the nurse include in her counseling?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. The lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds w/hemoglobin in the body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is crucial information because carbon monoxide binds to hemoglobin more strongly than oxygen, leading to oxygen deprivation in the body's tissues. This can result in serious health consequences, including brain damage and even death.
Explanation for why the other choices are incorrect:
A: Carbon monoxide is odorless, so it does not have a distinct odor.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body's ability to transport oxygen, rather than directly damaging the lungs.
E, F, G: No additional choices provided.
A nurse in an outpatient clinic is caring for a client who states she is trying to get pregnant. The client currently takes a Category D pregnancy risk medication for the control of seizures. Which of the following statements by the nurse is appropriate?
- A. This medication is prescribed if necessary but is known to cause adverse effects to the fetus.
- B. This medication has evidence indicating that it is safe to take during pregnancy and will not harm the fetus.
- C. This medication cannot be taken during pregnancy because the risk outweighs the potential benefits.
- D. This medication hasn't been studied in pregnant women but is believed to be safe for the fetus.
Correct Answer: A
Rationale: The correct answer is A. Category D medications have shown evidence of risk to the fetus in human studies but potential benefits may outweigh risks in certain situations. The nurse should inform the client about the risks and benefits of continuing the medication while trying to conceive. Choice B is incorrect because Category D medications are not considered safe during pregnancy. Choice C is incorrect as it is not entirely true that the risk always outweighs the benefits. Choice D is incorrect because assuming safety without evidence is risky. The nurse should provide accurate information to guide the client's decision-making.