a client with a sprained right ankle is learning to walk with a cane what action demonstrates effective teaching

ATI LPN

ATI PN Comprehensive Predictor

1. A client with a sprained right ankle is learning to walk with a cane. What action demonstrates effective teaching?

A. The client advances the cane 18 inches in front of the foot
B. The client holds the cane in the left hand
C. The client advances the cane and the right leg simultaneously
D. The client holds the cane with the elbow flexed at 60Â°

Correct answer: B

Rationale: When a client has a sprained right ankle, they should hold the cane in the opposite hand (left hand) to the affected leg for better support and balance. This positioning helps to reduce the weight on the injured leg while providing stability. Option A is incorrect because advancing the cane too far in front can lead to loss of balance. Option C is incorrect as it does not provide the necessary support for the injured leg. Option D is incorrect as the elbow should be slightly flexed but not necessarily at a specific angle.

2. What intervention is key when managing a client with delirium?

A. Administer antipsychotic medication to calm the client
B. Identify any reversible causes of delirium
C. Provide a low-stimulation environment
D. Increase environmental stimulation

Correct answer: B

Rationale: The correct intervention when managing a client with delirium is to identify any reversible causes. Delirium can be caused by various factors such as infections, medications, dehydration, or metabolic imbalances. Administering antipsychotic medications (Choice A) may worsen delirium and should be avoided unless necessary for specific indications. Providing a low-stimulation environment (Choice C) is beneficial as it can help reduce agitation and confusion in individuals with delirium. Increasing environmental stimulation (Choice D) is contraindicated as it can exacerbate symptoms in delirious patients. Therefore, the priority should be on identifying and addressing reversible causes to effectively manage delirium.

3. What are the risk factors for stroke, and how can it be prevented?

A. High cholesterol and hypertension; prevent with regular exercise
B. Obesity and smoking; prevent with medication and weight loss
C. Diabetes and alcohol consumption; prevent with regular checkups
D. Lack of exercise and poor diet; prevent with lifestyle changes

Correct answer: A

Rationale: The correct answer is A. High cholesterol and hypertension are significant risk factors for stroke. Regular exercise is an effective way to prevent stroke by managing these risk factors. Choice B is incorrect as while obesity and smoking are risk factors, preventing stroke through medication and weight loss is not the primary method. Choice C is incorrect as diabetes and alcohol consumption are risk factors, but preventing stroke through regular checkups is not as direct as managing cholesterol and hypertension. Choice D is incorrect as lack of exercise and a poor diet are indeed risk factors, but the prevention of stroke through lifestyle changes needs to specifically address high cholesterol and hypertension.

4. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?

A. Administer PRN haloperidol (Haldol) to decrease the need to walk
B. Assess the client's gait for steadiness
C. Restrain the client in a geriatric chair
D. Administer PRN lorazepam (Ativan) to provide sedation

Correct answer: B

Rationale: Assessing the client's gait for steadiness is the most appropriate action to ensure the safety of a client with dementia while walking. This allows the nurse to identify any issues that may increase the risk of falls or accidents. Administering PRN haloperidol or lorazepam is not indicated as the first-line approach in managing wandering behavior and can have adverse effects like increased risk of falls, confusion, or oversedation. Restraint use should be avoided whenever possible, as it can lead to physical and psychological harm to the client.

5. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?

A. Provide lemon-glycerin swabs
B. Encourage the client to eat soft foods
C. Avoid using toothpaste
D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.