Question

A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

Answer 1

Correct Answers:

The Client places partial weight on the affected leg

Rationale :

🔹In a three-point gait, the correct technique involves advancing both crutches and the non-weight-bearing (affected) leg together, followed by the unaffected leg, which bears the full weight.

🔹Placing partial weight on the affected leg contradicts this principle and poses a high risk for imbalance, falls, or delayed healing, especially in post-injury or post-operative conditions.

🔹Teaching correct crutch gait protects the client’s safety and promotes recovery.

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Answer 2

Correct Answers:

joint mobility maintained

Rationale :

🎯The goal of passive range-of-motion (PROM) in clients with paralysis or limited mobility is to preserve joint flexibility and prevent contractures.

🎯Maintaining joint mobility reflects successful prevention of musculoskeletal complications and supports the potential for future functional recovery.

🎯Passive movement does not improve strength but maintains the integrity of the joint capsule and surrounding tissues.

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Answer 3

Correct Answers:

Each movement is moved just to the point of resistance by the nurse

Rationale :

✍Proper ROM technique involves moving the joint slowly and gently until resistance is felt, without forcing the movement or causing pain.

✍This protects the muscles, ligaments, and joints from overstretching or injury and supports circulation.

✍For clients with mobility impairment, it’s essential to prioritize safety and comfort, particularly during passive exercises performed by the nurse.

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Answer 4

Correct Answers:

The patient will return to the contemplation or precontemplation phase

Rationale :

📌In the Transtheoretical Model of Change, a lapse in behavior such as resuming smoking often leads the patient to regress to a prior stage—contemplation (considering quitting again) or precontemplation (not considering quitting).

📌This model views relapse as part of the behavioral change cycle, and the nurse’s role is to reassess readiness and provide supportive counseling, not to judge or discourage the patient.

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Answer 5

Correct Answers:

The client is 71 years old.

Rationale :

💎Advanced age is a significant risk factor for healthcare-associated infections (HAIs) due to age-related changes such as impaired immunity, skin fragility, reduced mucociliary clearance, and multiple comorbidities.

💎Older adults are also more likely to require invasive devices or prolonged hospitalization, further elevating their infection risk.

💎Nurses must be especially vigilant with infection control in this population.

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Answer 6

Correct Answers:

''Your need for sleep will increase during periods of growth."

Rationale :

💎During adolescence, the body undergoes rapid physiological and neurological growth, increasing the need for adequate sleep (8–10 hours/night) to support development, cognitive function, mood stability, and immune health.

💎Educating teens on sleep requirements helps prevent problems like daytime fatigue, irritability, and decreased academic performance, reinforcing the importance of self-care during growth periods.

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Answer 7

Correct Answers:

Health belief model

Rationale :

📌The Health Belief Model (HBM) explains health behaviors based on an individual's perception of personal susceptibility to a disease, the severity of the illness, and the perceived benefits of changing behavior.

📌The nurse's belief that clients will stop smoking once they understand its dangers and benefits reflects the core of the HBM.

📌 It is widely applied in preventive health education and behavior change interventions.

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Answer 8

Correct Answers:

Auscultate the entire lung region to assess lung sounds

Rationale :

📌Immobility places patients at high risk for hypostatic pneumonia due to pooling of secretions in the lower lung fields, reduced chest expansion, and poor ventilation.

📌A complete respiratory assessment requires auscultation of anterior, posterior, and lateral lung fields, especially focusing on dependent areas where secretions accumulate.

📌Thorough auscultation ensures timely detection of abnormal breath sounds such as crackles or diminished airflow.

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Answer 9

Correct Answers:

A patient with neck surgery

Rationale :

⚫Logrolling is a technique used to move patients while maintaining spinal alignment, commonly required after cervical spine, thoracic spine, or neck surgery.

⚫This maneuver prevents spinal rotation and reduces the risk of neurologic injury or delayed healing.

⚫It requires two or more staff moving the patient in one coordinated motion to protect the spine.

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Answer 10

Correct Answers:

'' I will place a bath seat in my shower to use when I bathe.

Rationale :

📌Using a bath seat is a key fall-prevention strategy for clients with a history of falls or balance concerns.

📌Wet environments such as showers pose a significant risk, and seated bathing allows the client to maintain stability, conserve energy, and reduce the risk of slipping or falling.

📌This demonstrates client understanding of adaptive equipment and home safety modifications.

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QLexNursing

1 : A nurse is assessing a client's ability to ambulate with crutches using a three-point gait. Which of the following actions should the nurse identify as a risk to the client's safety?

2 : A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding Indicates successful goal achievement?

3 : A nurse is providing range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?

4 : The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning, what should the nurse anticipate?

5 : A nurse is reviewing the medical record for a client who has a health care-associated infection (HAI). The nurse should identify which of the following findings as a risk factor for acquiring an HAI?

6 : A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching?

7 : The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking, Which health care model is the nurse following?

8 : The nurse is assessing the patient for respiratory complications of immobility. Which action will the nurse take assessing, the respiratory system?

9 : A nurse is supervising the logrolling of a patient. To which patient is the nurse most likely providing care?

10 : A nurse is teaching a client who has a history of falls about home safety. Which of the following statements should the nurse identify as an indication that the client understands the instructions?