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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?

A.

Inspects crutches to ensure rubber tips are intact.

B.

Practices bicep and triceps isometric exercises.

C.

Progresses to foot touchdown and weight-bearing of the affected leg.

D.

Bears body weight on the palms of hands during the crutch gait.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A rationale

Using everyday language when explaining issues is the most important action. This ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.

Choice B rationale

Providing a very well-lit meeting space is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.

Choice C rationale

Speaking loudly and facing the client is important for ensuring the client can hear and understand the information. However, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.

Choice D rationale

Underlining key words on the written information can be a helpful strategy for emphasizing important points, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading.

Correct Answer is B

Explanation

Choice A rationale

Capillary refill time is 2 seconds. A capillary refill time of 2 seconds is within normal limits and is unlikely to affect the accuracy of the pulse oximetry reading.

Choice B rationale

2+ edema of fingers and hands. Edema can interfere with the accuracy of pulse oximetry readings by affecting the perfusion of the area where the sensor is placed. This can lead to falsely low oxygen saturation readings.

Choice C rationale

Radial pulse volume is 3+. A strong radial pulse indicates good peripheral perfusion, which should not negatively impact the accuracy of the pulse oximetry reading.

Choice D rationale

Blood pressure is 142/88 mm Hg. While elevated blood pressure can have various effects on the body, it is not likely to directly affect the accuracy of a pulse oximetry reading.

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