a client with left leg weakness is learning to use a cane what is the appropriate teaching point for this client
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 with NGN

1. What is an appropriate teaching point for a client with left-leg weakness learning to use a cane?

Correct answer: A

Rationale: The correct teaching point for a client with left-leg weakness learning to use a cane is to maintain two points of support on the ground at all times. This ensures stability and helps prevent falls. Choice B, using the cane on the weak side of the body, may lead to imbalance and decreased support. Choice C, advancing the cane a specific distance with each step, is not as crucial as maintaining two points of support. Choice D, advancing the cane and the strong leg simultaneously, may also compromise stability and support for the weak leg.

2. What is the first step in managing a client with delirium?

Correct answer: B

Rationale: The correct first step in managing a client with delirium is to identify any reversible causes of delirium. This is crucial because addressing the underlying cause can help in resolving delirium more effectively. Administering sedative or antipsychotic medications without addressing the root cause may not be helpful and can even worsen the condition. Limiting environmental stimulation, although important, is not the primary step in managing delirium.

3. What are key signs of a urinary tract infection (UTI) in older adults?

Correct answer: A

Rationale: The correct answer is A. In older adults, key signs of a UTI often include confusion and increased temperature. Confusion is a common symptom in the elderly when they have a UTI, and an increase in body temperature can indicate an infection. Choices B, C, and D are incorrect because while painful urination and frequent urination are common UTI symptoms in general, they may not be as prominent in older adults. Dizziness, headache, back pain, and fever can be associated with other conditions but are not typically key signs of a UTI in older adults.

4. Which of the following findings should the nurse anticipate in the medical record of a client with a pressure ulcer?

Correct answer: A

Rationale: The correct answer is A: Serum albumin level of 3 g/dL. A serum albumin level of 3 g/dL indicates poor nutrition, which is commonly seen in clients with pressure ulcers. Choice B, a Braden scale score of 20, is incorrect because a higher Braden scale score indicates a lower risk of developing pressure ulcers. Choice C, a Norton scale score of 18, is incorrect as it is a tool used to assess the risk of developing pressure ulcers, not a finding in a client with an existing pressure ulcer. Choice D, a hemoglobin level of 13 g/dL, is unrelated to pressure ulcers and does not directly reflect the nutritional status associated with this condition.

5. A nurse is teaching a client how to administer enoxaparin. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction for administering enoxaparin is to pinch the skin before injecting. Pinching the skin helps create a proper fold for subcutaneous injections like enoxaparin, ensuring proper delivery of the medication into the subcutaneous tissue. Choice A is incorrect because enoxaparin should be administered subcutaneously, not into the muscle. Injecting it into the muscle can lead to complications. Choice B is incorrect because massaging the injection site after administration can increase the risk of bleeding or bruising due to the anticoagulant properties of enoxaparin. Choice D is incorrect as it is a general instruction and does not specifically relate to the administration of enoxaparin.

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