VNSG 1323: Chapter 26 Prep U Questions

The nurse is reading documentation that indicates that a client has a Syme's amputation. Which client does the nurse associate with this condition?

Client with amputation at the foot Explanation: The client with an amputation at the foot has a Syme amputation. Other answers are incorrect.

The nurse is teaching a client who had a below-the-knee amputation about a temporary prosthetic limb. Which client statement requires further nursing teaching?

"I will tighten the belt when I go to sleep." Explanation: Further nursing teaching is needed when the client states that the belt should be tightened when going to bed. The belt should be loosened when the client is in bed, and tightened during ambulation. Other statements are accurate and do not require further nursing teaching.

Just before a client is to be on a tilt table, the nurse applies elastic stockings. The client asks why these are necessary. Which response from the nurse is correct?

"The stockings help compress vein walls, preventing blood from pooling in extremities, which can cause fainting. Explanation :Just before using a tilt table, the nurse applies elastic stockings. These stockings help to compress vein walls, thus preventing the pooling of blood in the extremities, which may trigger fainting.

A client is practicing use of a cane. While evaluating the client's technique, the nurse makes sure that the client's cane is at what distance from the side of the toes?

4 to 6 inches Explanation: The nurse teaches the client and the family to place the cane on the stronger side of the body and to stand upright with the cane 4 to 6 in (10-15 cm) to the side of the toes.

The nurse is caring for a client with postural hypotension. Which nursing intervention is appropriate?

Asking the client to dangle before moving from a reclining position Explanation: Having the client dangle before moving from a reclining position can help normalize blood pressure. Other interventions listed will not effectively decrease the risk for postural hypotension.

The nurse is evaluating a client's use of a leg prosthetic. Which client behavior indicates that further nursing teaching is necessary?

Cleanses the stump each morning Explanation: The client should clean the stump each evening, not the morning, to allow sufficient time for the skin to be moisture-free. All other actions are appropriate.

A nurse checks that two fingers can be placed between the client's axilla and the axillary bar of crutches. What condition does this technique help prevent?

Crutch palsy Explanation: With axillary crutches, there should be space for two fingers between the axilla and axillary bar to prevent crutch palsy (a weakened forearm, wrist, and hand muscles from nerve impairment secondary to pressure on the brachial plexus of nerves in the axilla) from incorrectly fitted crutches or poor posture.

A nurse is teaching a client using crutches to follow this pattern: one crutch, opposite foot, other crutch, remaining foot. What type of gait is the nurse instructing about?

Four Point Explanation: The four-point gait generally is used for clients with bilateral weakness or disability, such as arthritis or cerebral palsy. The gait pattern is one crutch, opposite foot, other crutch, remaining foot.

The client's strength and type of disability are guides to the best possible crutch-walking gait or style of walking. The client is using each crutch and each leg separately. What would be the best description of this type of crutch-walking gait to include in the documentation in the electronic medical record?

Four-point gait Explanation: With a four-point gait, each crutch and each leg move separately. With a two-point gait, the client is partially weight-bearing on both legs. With a three-point gait, each crutch and only one leg support weight. With a swing-through or tripod gait, the client stands on the strong leg, moves both crutches forward the same distance, rests their weight on the palms, and swings forward slightly ahead of the crutches.

A nurse is assisting a client to ambulate at the health care facility using a walking belt. How does the walking belt assist the client when ambulating?

It allows the nurse to support the client. Explanation: A walking belt provides support if the client loses balance when ambulating, thus preventing injuries. When assisting a client to ambulate, the nurse walks alongside the client, holding the walking belt or the client's own belt and supporting the client's arm. A quadriceps setting would aid the client in extending the leg. The use of parallel bars as handrails helps the client to gain practice when ambulating. Exercising the quadriceps muscles enables the client to stand and support body weight.

Which nursing strategy will prevent the dislocation of the hip prosthesis?

Maintaining abduction Explanation: The nurse should take special care to prevent adduction of the affected leg and hip. To avoid this, some orthopedic surgeons order abductor pillows. The other listed actions would be likely to cause dislocation.

A nurse is evaluating an older client's functional ability. What factors would the nurse include in this evaluation?

Mobility and ability to compensate for age-related changes Explanation: An older adult's self-perception is often linked to their functional ability. Functional ability involves both mobility and making adaptations to compensate for changes occurring with aging or disease processes.

A client requires crutches but cannot bear any weight with the hands or wrists. What type of crutches would the nurse prepare to assist this client with?

Platform Crutches Explanation: The three basic types of crutches are axillary, forearm, and platform. Axillary crutches (the standard type) have a bar that fits beneath the axilla. Clients who need brief, temporary assistance with ambulation are likely to use axillary crutches. Lofstrand and Canadian crutches are examples of forearm crutches, which have an arm cuff but no axillary bar. Forearm crutches generally are used by experienced clients who need permanent assistance with walking. Platform crutches support the forearm and are used by clients who cannot bear weight with their hands and wrists

A nurse is educating an older adult client on how to use a walker. Which instructions to the client ensure accurate use of this device? Select all that apply.

Stand between the back legs of the walker. Keep arms relaxed at the side. Line up the top of the walker with the crease on the inside of your wrist. Explanation: Regardless of the type of walker used, the client stands between the back legs of the walker with arms relaxed at the side. The top of the walker should line up with the crease on the inside of the client's wrist. When the client's hands are placed on the grips, elbows should be flexed. Have the client move the walker forward 6 to 8 inches and set it down, making sure all four feet of the walker stay on the floor. Then, tell the client to step forward with either foot into the walker, supporting himself on his arms. Follow through with the other leg.

A bedridden client has become debilitated. What would the nurse include in the client's plan of care to prepare him for ambulation? Select all that apply.

Upper arm strengthening Isometric exercises Tilt table Dangling Explanation: Debilitated clients require physical conditioning before they can ambulate again. Performing isometric exercises, upper arm strengthening, dangling at the bedside, and using a tilt table help to increase muscle strength and the ability to bear weight.