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. 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.

3. Death of bone tissue can occur when the blood supply to the bone is disrupted. What is this complication called?

Correct answer: B

Rationale: The correct answer is B, avascular necrosis. Avascular necrosis is the condition where bone tissue dies due to the disruption of blood supply to the bone. Reflex sympathetic dystrophy (Choice A) is a chronic pain condition, delayed union (Choice C) refers to a delayed healing of a fracture, and complex regional pain syndrome (Choice D) is a chronic pain condition typically affecting an arm or leg.

4. The nurse will be using the Braden Scale with each admit to the long-term care center. Which of these will NOT be utilized in a Braden Scale Assessment?

Correct answer: A

Rationale:

5. Antibodies are passed from mother to fetus through the placenta. What is this type of immunity called?

Correct answer: B

Rationale:

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