a nurse is teaching a client about the proper use of a cane which of the following instructions should the nurse include a nurse is teaching a client about the proper use of a cane which of the following instructions should the nurse include
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. When teaching a client about the proper use of a cane, which of the following instructions should be included?

Correct answer: B

Rationale: When using a cane, it is crucial to move the cane forward first to provide support and enhance balance. Advancing the cane before the weaker or stronger leg helps widen the base of support, thereby improving stability during ambulation. Keeping the cane too far or too close to the body can affect its supportive function. Moreover, utilizing the cane solely for stair climbing limits its overall utility in maintaining balance and stability during regular walking.

2. What is the primary benefit of using exposure therapy for patients with phobias?

Correct answer: B

Rationale: The primary benefit of using exposure therapy for patients with phobias is to gradually reduce the patient's fear and anxiety. Exposure therapy involves exposing the individual to the feared object or situation in a controlled manner to help them confront their fears and learn that the perceived threat is not as harmful as initially believed. Over time, repeated exposure can lead to a decrease in anxiety and fear responses, helping the individual manage and overcome their phobia. Choice A is incorrect because exposure therapy aims to reduce fear and anxiety, not necessarily eliminate the phobia completely. Choice C is incorrect as although relaxation techniques might be part of the therapy, the primary goal is fear reduction. Choice D is incorrect as exposure therapy typically involves gradual exposure rather than providing immediate relief.

3. Which hormone is responsible for stimulating the gallbladder to contract and release bile?

Correct answer: B

Rationale: Cholecystokinin (CCK) is the correct answer. It is the hormone responsible for stimulating the gallbladder to contract and release bile to aid in fat digestion. Gastric lipase (Choice A) is an enzyme that breaks down fats in the stomach, not a hormone involved in gallbladder function. Vitamin D (Choice C) is important for calcium absorption and bone health, but it is not directly related to gallbladder function. Enterokinin (Choice D) is a peptide hormone that affects smooth muscle contractions in the gastrointestinal tract, but it is not specifically responsible for stimulating the gallbladder to release bile.

4. What is the primary action the nurse should take first for a client with a pressure ulcer who has a serum albumin level of 3 g/dL?

Correct answer: B

Rationale: The correct answer is to consult with a dietitian to create a high-protein diet. A serum albumin level of 3 g/dL indicates hypoalbuminemia, which can impair wound healing. Consulting with a dietitian to optimize the client's protein intake is crucial in promoting wound healing for pressure ulcers. Increasing the protein intake in the diet (Choice A) may not be sufficient without proper guidance from a dietitian. Increasing the IV fluid infusion rate (Choice C) is not directly related to addressing the protein deficiency. Administering a protein supplement (Choice D) should be guided by a healthcare professional's recommendation after consulting with a dietitian.

5. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

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