Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching?
A. The client moves the cane 2 feet ahead.
Moving the cane 2 feet ahead is too far and can cause imbalance or a fall. The cane should be moved a short distance ahead, about the length of one natural step.
B. The client holds the cane with their right hand.
Holding the cane with the right hand is correct for someone with left-sided weakness. The cane should be used on the stronger side of the body to provide support for the weaker side.
C. The client takes a step with their left foot first.
Taking a step with the left foot first is not correct because the weaker leg should be advanced to the cane to ensure stability and support when moving.
D. The client advances the weaker (left) leg forward to the cane.
Advancing the weaker leg forward to the cane is correct. The cane provides support for the weaker leg, helping to maintain balance as the client walks.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Moving the cane 2 feet ahead is too far and can cause imbalance or a fall. The cane should be moved a short distance ahead, about the length of one natural step.
Choice B reason: Holding the cane with the right hand is correct for someone with left-sided weakness. The cane should be used on the stronger side of the body to provide support for the weaker side.
Choice C reason : Taking a step with the left foot first is not correct because the weaker leg should be advanced to the cane to ensure stability and support when moving.
Choice D reason: Advancing the weaker leg forward to the cane is correct. The cane provides support for the weaker leg, helping to maintain balance as the client walks.
Similar Questions
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will draw the regular insulin into the syringe first."
Drawing the regular insulin into the syringe first is correct. When mixing two types of insulin, the clear (regular) insulin should be drawn up before the cloudy (NPH) insulin to prevent contamination.
B. "I will store prefilled syringes in the refrigerator with the needle pointed upward."
Storing prefilled syringes with the needle pointed upward can cause air bubbles to move into the insulin, which can alter the dose when injected. The needle should be pointed downward.
C. "I will gently roll the NPH vial between my hands before drawing up the insulin."
Shaking the NPH vial vigorously is not recommended as it can create air bubbles and affect the insulin dose. Instead, the vial should be gently rolled between the hands to mix the insulin.
D. "I will insert the needle at a 90-degree angle."
Inserting the needle at a 15-degree angle is incorrect for subcutaneous injections. A 90-degree angle is typically used unless the patient is very thin, in which case a 45-degree angle may be used.
Full Explanation
Choice A reason: Drawing the regular insulin into the syringe first is correct. When mixing two types of insulin, the clear (regular) insulin should be drawn up before the cloudy (NPH) insulin to prevent contamination.
Choice B reason: Storing prefilled syringes with the needle pointed upward can cause air bubbles to move into the insulin, which can alter the dose when injected. The needle should be pointed downward.
Choice C reason: Shaking the NPH vial vigorously is not recommended as it can create air bubbles and affect the insulin dose. Instead, the vial should be gently rolled between the hands to mix the insulin.
Choice D reason: Inserting the needle at a 15-degree angle is incorrect for subcutaneous injections. A 90-degree angle is typically used unless the patient is very thin, in which case a 45-degree angle may be used.
A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow?
A. "Do you feel like you have food stuck at the base of your throat?"
Asking if the client feels like they have food stuck at the base of their throat is a pertinent question for assessing swallowing in a client with oral achalasia. Achalasia is characterized by difficulty in swallowing due to the inability of the lower esophageal sphincter to relax, leading to a sensation of food being stuck.
B. "Do you feel any burning sensations in your throat?"
While burning sensations in the throat can be associated with gastroesophageal reflux disease (GERD), they are not specific to achalasia. However, some clients with achalasia may experience similar symptoms due to food stasis and fermentation in the esophagus.
C. "Do you have any feelings of fullness in the neck?"
Feelings of fullness in the neck are not a typical symptom of achalasia. Achalasia primarily affects the esophagus and does not usually cause a sensation of fullness in the neck.
D. "Do you have any problems with pain while swallowing?"
Pain while swallowing, or odynophagia, can occur in achalasia but is more commonly associated with conditions that cause inflammation or irritation of the esophagus, such as infections or ingestion of irritants.
Full Explanation
Choice A reason: Asking if the client feels like they have food stuck at the base of their throat is a pertinent question for assessing swallowing in a client with oral achalasia. Achalasia is characterized by difficulty in swallowing due to the inability of the lower esophageal sphincter to relax, leading to a sensation of food being stuck.
Choice B reason: While burning sensations in the throat can be associated with gastroesophageal reflux disease (GERD), they are not specific to achalasia. However, some clients with achalasia may experience similar symptoms due to food stasis and fermentation in the esophagus.
Choice C reason: Feelings of fullness in the neck are not a typical symptom of achalasia. Achalasia primarily affects the esophagus and does not usually cause a sensation of fullness in the neck.
Choice D reason: Pain while swallowing, or odynophagia, can occur in achalasia but is more commonly associated with conditions that cause inflammation or irritation of the esophagus, such as infections or ingestion of irritants.
A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make?
A. "Were you careful to not have carbohydrates after the run?"
Advising the client to avoid carbohydrates after exercise is not appropriate. Carbohydrates are necessary to replenish glycogen stores after exercise, and individuals with diabetes need to monitor their blood sugar levels to manage carbohydrate intake accordingly.
B. "It is normal to feel this way after a morning run."
Saying it is normal to feel exhausted after a morning run does not address the client's symptoms of diaphoresis, increased heart rate, and palpitations, which could be signs of hypoglycemia, a common risk for individuals with type 1 diabetes after exercise.
C. "It becomes easier when exercise is a routine."
While it's true that exercise can become easier with routine, this statement does not address the client's immediate concerns about their symptoms following exercise.
D. "Did you decrease your insulin intake before you exercised?"
Asking if the client decreased their insulin intake before exercising is an appropriate response. Individuals with type 1 diabetes need to adjust their insulin dosage to account for physical activity, which can significantly lower blood glucose levels.
Full Explanation
Choice A reason: Advising the client to avoid carbohydrates after exercise is not appropriate. Carbohydrates are necessary to replenish glycogen stores after exercise, and individuals with diabetes need to monitor their blood sugar levels to manage carbohydrate intake accordingly.
Choice B reason: Saying it is normal to feel exhausted after a morning run does not address the client's symptoms of diaphoresis, increased heart rate, and palpitations, which could be signs of hypoglycemia, a common risk for individuals with type 1 diabetes after exercise.
Choice C reason: While it's true that exercise can become easier with routine, this statement does not address the client's immediate concerns about their symptoms following exercise.
Choice D reason: Asking if the client decreased their insulin intake before exercising is an appropriate response. Individuals with type 1 diabetes need to adjust their insulin dosage to account for physical activity, which can significantly lower blood glucose levels.