the nurse has the client move both crutches forward with weight on the unaffected leg and move the unaffected leg forward shifting weight onto the una
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Nursing Elites

ATI RN

Multi Dimensional Care | Final Exam

1. The client moves both crutches forward, with weight on the unaffected leg, and then moves the unaffected leg forward, shifting weight onto it. Which of the following gaits is being utilized?

Correct answer: B

Rationale: The correct answer is B, Three-point gait. In a three-point gait, one leg is non-weight bearing, as described in the scenario where the client shifts weight onto the unaffected leg. Choices A, C, and D are incorrect. A two-point gait involves partial weight-bearing on both legs, a four-point gait involves weight-bearing on both legs, and 'Unaffected gait' is not a recognized term in gait patterns.

2. A nurse is teaching a client who has out about dietary recommendations. The nurse should teach the client which of the following beverages can trigger an attack?

Correct answer: B

Rationale:

3. What observation by the nurse indicates the need for further teaching to unlicensed assistive personnel (UAP) on assisting with ambulation?

Correct answer: C

Rationale: Choice C is the correct answer because the UAP should walk slightly behind or to the side of the client, not in front, to provide proper support during ambulation. Choices A, B, and D are not indicative of incorrect technique or the need for further teaching. Putting shoes on the client, removing floor rugs and loose objects, and using a transfer (gait) belt are all appropriate actions when assisting with ambulation.

4. A client states that he has been experiencing oozing from his wounds. What is the nurse's priority action?

Correct answer: D

Rationale:

5. What is the priority nursing diagnosis for a client with immobility?

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

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