A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse's BEST response?

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Question 1 of 5

A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse's BEST response?

Correct Answer: A

Rationale: In the four-point gait when partial weight bearing is permitted, the correct technique is to move the right crutch ahead, then follow with the left foot. This technique provides the most stability and support for the individual while allowing for proper weight distribution and balance. Moving the crutches and legs in a coordinated fashion helps prevent falls and ensures the safe ambulation of the client.

Question 2 of 5

A client with serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?

Correct Answer: A

Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.

Question 3 of 5

A 15-month-old toddler was able to do all the following EXCEPT

Correct Answer: D

Rationale: Responding to name usually occurs earlier, around 6-9 months.

Question 4 of 5

Hemangiomas are the most common benign tumors of infancy, occurring more in full-term infants. Of the following, the most common risk factor of development of hemangioma is

Correct Answer: B

Rationale: Female infants are at higher risk for developing hemangiomas.

Question 5 of 5

Which is the most reliable method for monitoring fluid balance?

Correct Answer: A

Rationale: Monitoring daily intake and output is the most reliable method for assessing fluid balance in a patient. By accurately measuring the amount of fluids taken in through foods, drinks, and IV fluids, as well as the amount of fluids eliminated through urine, stool, vomit, and other means, healthcare providers can closely track the body's fluid balance. Discrepancies between intake and output can indicate potential issues such as dehydration or fluid overload. This method provides quantitative data that can guide appropriate interventions and treatment adjustments to maintain the patient's fluid balance within normal limits. While vital signs, daily weight, and skin turgor are also important indicators of fluid status, they may not always provide as specific or accurate information as the direct measurement of intake and output.

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