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?
Inspects crutches to ensure rubber tips are intact.
Practices bicep and triceps isometric exercises.
Progresses to foot touchdown and weight-bearing of the affected leg.
Bears body weight on the palms of hands during the crutch gait.
The Correct Answer is D
Choice A rationale
Inspecting crutches to ensure rubber tips are intact is important for safety, but it does not indicate an understanding of the proper crutch walking technique. Proper crutch walking involves using the crutches correctly to avoid injury and ensure mobility.
Choice B rationale
Practicing bicep and triceps isometric exercises can help strengthen the muscles needed for crutch walking, but it does not demonstrate an understanding of the actual crutch walking technique. The focus should be on how the crutches are used during walking.
Choice C rationale
Progressing to foot touchdown and weight-bearing of the affected leg is a part of the rehabilitation process, but it does not specifically indicate proper crutch walking technique. Proper crutch walking involves the correct use of crutches to support the body weight.
Choice D rationale
Bearing body weight on the palms of hands during the crutch gait is the correct technique for three-point gait crutch walking. This method ensures that the weight is distributed properly and reduces the risk of injury to the underarms and shoulders.
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View Related questions
Correct Answer is C
Explanation
Choice A rationale
Giving the client a hug and saying, “It is okay to cry when you are sad,” may be comforting, but it may also be seen as intrusive and not respecting the client’s personal space. Physical touch should be used cautiously and only when the nurse is certain that it is welcome and appropriate. Additionally, this response does not encourage the client to express their feelings or provide an opportunity for the nurse to understand the underlying cause of the client’s distress.
Choice B rationale
Saying, “I am sorry to disturb you at a difficult time. This can wait until later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.
Choice C rationale
While touching the client’s forearm, asking, “Would you like to talk about it?” is the best response as it shows empathy and offers the client an opportunity to express their feelings. This response respects the client’s personal space while also providing a gentle touch that can be comforting. It opens the door for communication and allows the nurse to provide emotional support and address any concerns the client may have.
Choice D rationale
Saying, “This is a bad time. I can see you are upset. I can come back later,” acknowledges the client’s distress but does not offer immediate support or an opportunity for the client to express their feelings. It may also give the impression that the nurse is not available to provide emotional support when needed.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Determine client’s subjective measure of pain using a numerical pain scale. Assessing the client’s pain using a numerical pain scale allows the nurse to understand the client’s perception of their pain and to monitor changes over time. This is a crucial step in managing chronic pain as it provides a baseline for evaluating the effectiveness of interventions.
Choice B rationale
Implement a 24-hour schedule of routine administration of prescribed analgesic. Chronic pain management often requires a consistent and routine administration of analgesics to maintain a stable level of pain control. This approach helps to prevent the peaks and troughs of pain that can occur with as-needed dosing.
Choice C rationale
Assist the client to ambulate as much as possible during waking hours. While ambulation can be beneficial for some clients, it may not be appropriate for all clients with chronic pain, especially if the pain is severe or if ambulation exacerbates the pain. Therefore, this intervention should be individualized based on the client’s condition.
Choice D rationale
Provide comfort measures such as topical warm application and tactile massage. Non- pharmacological interventions such as warm applications and massage can help to alleviate pain and improve comfort. These measures can be used in conjunction with pharmacological treatments to provide a more comprehensive approach to pain management.
Choice E rationale
Encourage increased fluid intake and measure urinary output every 8 hours. While maintaining adequate hydration is important, this intervention is not directly related to the management of chronic pain. It may be more relevant for clients with other conditions such as renal issues.