Mr Smith is using a cane for assistance with ambulation.While using his cane for assistant the nurse should be aware that patient should do what?.
A. Move the weaker foot ahead of the cane. B.Mr Smith should hold his cane on the weaker side and the nurse on the stronger side.
C.Mr Smith should distribute his weight evenly between his feet and the cane. D.Keep the elbows stiff and straight looking forward.
Correct answer is C. Mr Smith should distribute his weight evenly between his feet and the cane.To hold the cane on the weak side is not safe. The elbow should be flexed at a 30degree angle and not stiff.Moving the weaker foot forward is not safe and can lead to fall.
2.As a nurse you admitted a blind bedridden patient from his home with a sacral pressure. What will be a priority nursing diagnosis on this patient?.
A.Alteration in nutrition related to inability to feed himself.
B. Activity intolerance related to prolonged bed rest.
C.High risk for infection related to bedsore. D.Impaired Skin integrity related to immobility.
The correct answer is D.The priority upon admission of this patient is impaired skin integrity related to immobility. This calls for immediate actions on care of wound. (Wound consult, pictures of wound taken,wound assessment and measuremen,reposition for pressure redistribution and comfort ).The other nurse diagnosis are appropriate but not the priority. Patient is blind and needs assistance with feeding,his ADL etc.