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Zorluk: OrtaBasic Care and Comfort

A nurse is planning care for a client who has left lower extremity weakness and is learning to ambulate with a standard pick-up walker. Which of the following interventions should the nurse include in the plan of care?

  1. A
    Delegate the evaluation of the client's balance and gait during the initial ambulation to an unlicensed assistive personnel (UAP).
  2. B
    Adjust the height of the walker so that the client's elbows are fully extended when resting their hands on the grips.
  3. Instruct the client to advance the walker forward first, step forward with the left leg, and then bring the right leg forward.Cevap
  4. D
    Teach the client to take an initial step with the strong right leg first while simultaneously advancing the walker.

Cevap

The correct intervention is to instruct the client to advance the walker forward first, step forward with the weak left leg, and then bring the right leg forward.
When ambulating with a standard walker, the client should first lift and advance the walker about 6 to 8 inches. Next, the client should step forward with the affected (weak) leg so that the upper body and the walker can safely support the body's weight. Finally, the client steps forward with the unaffected (strong) leg. This sequence ensures a wide base of support and maximum stability.

Adım Adım Çözüm

1
Identify the client's physical deficit and the assistive device being utilized.
The client has left lower extremity weakness and is using a standard pick-up walker.
Recognizing which leg is affected is critical for determining the safe and correct sequence of movement.
2
Determine the proper ambulatory sequence for using a standard walker.
The correct sequence is to move the walker forward, followed by the weak leg, and finally the strong leg.
Moving the weak leg while the upper body weight is supported by the arms on the walker provides maximum stability and safety.
3
Evaluate the distractors for safety, body mechanics, and procedural accuracy.
The distractors contain critical errors related to walker height adjustment, stepping sequence, and improper delegation.
Identifying incorrect practices ensures the selection of the safest, most appropriate evidence-based nursing intervention.

Anahtar Kavram

Assistive Devices and Mobility
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Konular

Basic Care and Comfort

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