- An 80-year-old client is learning walker use after hip replacement. The client has mild cognitive impairment and lives with a daughter who works during the day. Which nursing intervention is MOST appropriate to promote safe walker use at home?
Answer: Provide simple, step-by-step instructions and have the client return-demonstrate walker use in a simulated home setup with obstacles removed
This question tests understanding of assistive devices and client teaching for walker use in cognitively impaired clients. The primary teaching point is simplifying instructions and using simulations for safe home practice. Option A is the best choice because step-by-step guidance with return demonstration accommodates cognitive needs and promotes independence. Options B, C, and D are less optimal: B fosters dependency; C delays teaching; and D risks tripping. Effective client teaching adapts to cognitive levels. A principle of device use is environmental modification. A transferable strategy is to involve caregivers in simulated practice.
- A 55-year-old client with multiple sclerosis has worsening hand weakness and uses built-up handles and a rocker knife for feeding. The client lives alone and reports coughing during meals when trying to eat quickly. What is the PRIORITY action the nurse should take?
Answer: Encourage the client to take smaller bites, sit upright, and pace the meal; notify the registered nurse of possible swallowing difficulty.
The priority is to protect the airway when a client using adaptive equipment reports coughing during meals, because coughing can indicate dysphagia and aspiration risk. The option that combines small bites, upright positioning, pacing, and referral to the registered nurse is the only one that addresses both immediate safety and the need for further swallowing evaluation. Switching to regular utensils removes needed adaptive support for worsening hand weakness and does not address the cough. Drinking thin liquids—or adding carbonated beverages—is unsafe because thin liquids are more likely to enter the airway in a client with possible dysphagia. Eating while lying down increases aspiration risk regardless of head position, so it is not a reasonable fatigue-reducing alternative. Therefore, the best action is the one that implements aspiration precautions and notifies the registered nurse.
- A 7-year-old child with spastic cerebral palsy uses a wheelchair and is being discharged home. The child's parent says, "I pull on his arms to lift him from the wheelchair to the bed because it's faster." What is the PRIORITY nursing response?
Answer: Teach the parent to use a gait belt and to lift using the child's trunk/hips, not by pulling on the arms.
This question tests understanding of assistive devices and client teaching, specifically safe transfer techniques for children with cerebral palsy. The primary concern is preventing injury to both the child and caregiver while maintaining the child's joint integrity and muscle tone. The correct answer (A) is the BEST choice because it provides proper body mechanics instruction using a gait belt and emphasizes lifting from the trunk/hips rather than pulling on arms, which could cause shoulder dislocation or increased spasticity. Option B is unsafe as the child requires assistance due to spasticity; option C is impractical and unnecessarily restrictive; option D is incorrect because lifting under the armpits can cause injury and quick movements can trigger increased spasticity. Effective transfer teaching must address both safety and the specific neuromuscular considerations of cerebral palsy. When teaching caregivers of children with spasticity, emphasize slow, controlled movements and proper body mechanics to prevent injury while managing muscle tone.
- A 79-year-old client is learning to use a walker after hip replacement and is preparing for discharge to a home with two steps at the entrance and no handrail. The client says, "I'll just carry the walker up the steps." Which client statement indicates a need for further instruction about the walker?
Answer: "I will carry the walker while stepping up so I can use the other hand to balance."
This question tests understanding of assistive devices and client teaching for walker use after hip replacement in homes with stairs. The primary teaching point is safe stair navigation without carrying the walker to prevent imbalance and falls. Option C indicates a need for further instruction because carrying the walker risks loss of support and injury, especially without a handrail. Options A, B, and D are appropriate: A seeks help or modifications; B maintains posture; and D clears paths. Effective client teaching includes scenario-based practice for stairs. A principle of device use is adapting techniques to environmental barriers safely. A transferable strategy is to use role-playing for hazardous situations to reinforce safe alternatives.
- A 27-year-old client with a new prosthetic leg reports the prosthesis "clicks" and feels loose when walking. The client has diabetes and decreased sensation in the residual limb. Which action should the nurse take FIRST?
Answer: Inspect the residual limb skin and ask about wear time, sock ply, and any recent weight changes before advising follow-up with the prosthetist
This question tests understanding of assistive devices and client teaching for prosthetic issues like looseness and noise. The primary teaching point is assessing factors affecting fit, such as weight changes or sock use, especially with diabetes-related sensation loss. Option B is the best choice because inspecting the limb and gathering history guides safe follow-up, preventing complications like falls or skin damage. Options A, C, and D are incorrect: A risks instability; C and D introduce improper modifications. Effective client teaching involves holistic assessment before interventions. A principle of device use is monitoring for changes in body condition affecting fit. A transferable strategy is to collaborate with specialists like prosthetists for ongoing device adjustments.
- A 28-year-old client with a new prosthetic leg asks how to care for the prosthetic liner and residual limb. The client works outdoors and sweats heavily and reports a "musty smell" inside the socket. Which information is MOST important to include in teaching?
Answer: Clean and thoroughly dry the liner and residual limb daily, and do not apply powders or lotions before wearing unless directed.
This question tests understanding of assistive devices and client teaching, specifically prosthetic hygiene and skin care. The primary concern is preventing skin breakdown and infection through proper cleaning and drying techniques, especially important for clients who sweat heavily. The correct answer (A) is the BEST choice because daily cleaning and thorough drying prevents bacterial and fungal growth while avoiding powders/lotions that can cause skin maceration or interfere with prosthetic fit. Option B is incorrect as hot water can damage prosthetic materials; option C is dangerous because overnight wear prevents skin inspection and can cause pressure sores; option D is extremely unsafe as modifying the prosthesis can compromise fit and function. Effective prosthetic teaching emphasizes meticulous hygiene as the foundation for preventing complications. When teaching clients who work in conditions causing heavy perspiration, stress the importance of moisture management and consider recommending moisture-wicking liners or additional liner changes during the day.
- A 63-year-old client post-stroke uses a cane and reports near-falls when turning quickly in the kitchen. The client lives with an adult child and has mild left neglect. Which instruction is MOST important to reduce fall risk when using the cane?
Answer: Take small steps when turning, pivot slowly, and pause to regain balance before continuing
This question tests understanding of assistive devices and client teaching for cane use in post-stroke clients with neglect. The primary teaching point is safe turning techniques to minimize fall risk in confined spaces like kitchens. Option A is the best choice because small, slow pivots with pauses enhance stability and awareness, addressing near-falls. Options B, C, and D are incorrect: B teaches wrong side; C increases tripping; and D slips on floors. Effective client teaching focuses on high-risk activities. A principle of device use is adapting gait for environmental challenges. A transferable strategy is to simulate home scenarios in teaching sessions.
- A 62-year-old client recovering from an ischemic stroke is using a cane for the first time. The client lives with a spouse in a one-story home and reports feeling unsteady when walking from the bedroom to the bathroom at night. What should the nurse do FIRST when assisting the client with the cane?
Answer: Assess the cane height and gait pattern, then reinforce placing the cane on the stronger side and moving it with the weaker leg
This question tests understanding of assistive devices and client teaching for cane use after a stroke. The primary teaching point is ensuring proper cane placement and gait to promote balance and prevent falls, especially at night. Option B is the best choice because assessing fit and reinforcing correct technique—cane on the stronger side moved with the weaker leg—addresses unsteadiness and supports safe ambulation. Options A, C, and D are incorrect: A teaches improper placement; C encourages unsafe furniture reliance; and D escalates to a walker prematurely without assessment. Effective client teaching includes hands-on demonstration and correction of technique. A principle of device use is fitting the device to the client's body mechanics for optimal support. A transferable strategy is to prioritize assessment and immediate correction of improper use before advancing to complex scenarios.
- A 12-year-old child with cerebral palsy uses a wheelchair and is transported in a family van. The caregiver asks how to secure the child safely during travel. Which instruction is MOST important?
Answer: Use an approved wheelchair tie-down system and a separate passenger restraint (seat belt) for the child, following manufacturer instructions
This question tests understanding of assistive devices and client teaching for wheelchair transportation safety. The primary teaching point is using proper restraints to secure both chair and child during travel. Option A is the best choice because approved tie-downs and belts prevent movement and injury in vehicles. Options B, C, and D are incorrect: B relies on brakes; C mispositions; and D inadequately secures. Effective client teaching references guidelines. A principle of device use is stability in motion. A transferable strategy is to demonstrate securing techniques with families.
- A 7-year-old child with cerebral palsy uses a wheelchair. The parent reports new redness on the child's sacrum after long school days. What is the PRIORITY nursing action?
Answer: Teach the family to perform regular pressure relief and repositioning, and assess seating cushion fit and skin daily
This question tests understanding of assistive devices and client teaching for pressure injury prevention in wheelchair users. The primary teaching point is implementing relief measures and assessments to address sacral redness from prolonged sitting. Option A is the best choice because regular repositioning and checks prevent progression to ulcers, prioritizing skin integrity. Options B, C, and D are incorrect: B risks burns; C causes dehydration; and D promotes moisture. Effective client teaching empowers families with monitoring skills. A principle of device use is pressure redistribution. A transferable strategy is to integrate skin assessments into daily routines.
- A 56-year-old client with multiple sclerosis has fatigue and decreased hand strength and is using adaptive utensils. The client says, "I'll only use them when someone is watching so I don't spill." Which response by the nurse is MOST appropriate to support safe, independent feeding?
Answer: Encourage use of adaptive utensils consistently and suggest energy conservation strategies such as resting before meals and using a non-slip mat
This question tests understanding of assistive devices and client teaching for adaptive utensils in multiple sclerosis to foster independence. The primary teaching point is promoting consistent use and fatigue management to ensure safe, self-feeding despite hand weakness. Option A is the best choice because it encourages regular practice with supportive strategies, addressing reluctance and spillage concerns. Options B, C, and D are incorrect: B limits nutrition; C devalues independence; and D risks fatigue. Effective client teaching builds confidence through positive reinforcement. A principle of device use is integrating energy conservation for chronic conditions. A transferable strategy is to combine device teaching with lifestyle adaptations for holistic support.
- A 31-year-old client with a prosthetic limb reports pain and a "burning" sensation in the residual limb during walking. The client recently started a new job requiring more standing. What is the PRIORITY action the nurse should take?
Answer: Assess the residual limb for skin breakdown and fit issues, and instruct the client to remove the prosthesis and rest if pain occurs
This question tests understanding of assistive devices and client teaching for prosthetic pain management. The primary teaching point is assessing for breakdown and advising rest to prevent injury from increased activity. Option A is the best choice because inspection and removal if painful prioritize safety and healing. Options B, C, and D are less optimal: B ignores causes; C causes slippage; and D overexerts. Effective client teaching emphasizes symptom recognition. A principle of device use is gradual activity increase. A transferable strategy is to teach pain as a signal for immediate action.
- A 77-year-old client is using a walker after hip replacement and is practicing in the hallway. The nurse observes the client lifting the walker and placing it far ahead, then taking a large step and losing balance. What should the nurse do FIRST?
Answer: Instruct the client to move the walker a short distance forward, keep all four legs on the floor, and step into the walker one step at a time
The nurse's first priority is to prevent a fall by correcting the unsafe walker technique. The client is lifting the walker too far ahead and taking a large step, which compromises stability. The correct action is to instruct the client to move the walker a short distance forward, keep all four legs on the floor, and step into it one step at a time. Asking physical therapy to re-evaluate the device is a delayed response; the nurse can immediately correct the technique. Teaching stair climbing is irrelevant because the client's problem is on level ground. Increasing pain medication is unwarranted because pain has not been identified as the cause of the balance issue. Therefore, direct, real-time teaching is the best first action.
- A 66-year-old client recovering from a stroke uses a cane and has right-sided weakness. During hallway ambulation with the nurse, the client begins to sway and says, "I'm getting dizzy." What should the nurse do FIRST?
Answer: Support the client, have the client sit down immediately (or lower to a safe surface), and assess vital signs.
This question tests understanding of assistive devices and client teaching, specifically emergency response during ambulation with assistive devices. The primary concern is preventing injury when a client experiences sudden dizziness during ambulation, which could indicate orthostatic hypotension, cardiac issues, or stroke-related complications. The correct answer (B) is the BEST choice because it prioritizes immediate safety by supporting the client and facilitating a controlled descent to sitting (or to the floor if necessary), followed by vital sign assessment to determine the cause. Option A is dangerous as continuing to walk increases fall risk; option C delays necessary immediate intervention; option D addresses technique but ignores the acute safety issue. Effective assistive device teaching must include emergency protocols for managing sudden symptoms during ambulation. When clients experience dizziness or weakness during ambulation, the priority is always 'support and sit' to prevent falls, followed by assessment of the underlying cause.
- A 54-year-old client with Parkinson disease has increasing tremors and rigidity and is now using adaptive utensils at meals. The client lives with a partner and reports, "I'm embarrassed, so I just skip meals." Which client statement indicates a need for further instruction about adaptive utensils?
Answer: "I should avoid using adaptive utensils because they will make my hand muscles weaker."
This question tests understanding of assistive devices and client teaching for adaptive utensils in Parkinson disease to promote independence. The primary concern is addressing embarrassment and encouraging consistent use to maintain nutrition without weakening muscles. Option C indicates a need for further instruction because avoiding adaptive utensils does not weaken muscles and can actually support better function and self-care. Options A, B, and D are correct statements: A and D aid stability and containment; B improves grip ease. Effective client teaching normalizes device use and focuses on benefits. A principle of device use is selecting tools that compensate for deficits without promoting dependency. A transferable strategy is to address psychosocial barriers like embarrassment through empathetic discussion and success stories.
- A 10-year-old child with cerebral palsy uses a wheelchair. The caregiver reports the child slides forward in the seat and the feet dangle because the footrests "are in the way." Which teaching is MOST important?
Answer: Adjust the footrests so thighs are supported and feet rest flat on the footplates to improve posture and reduce skin breakdown risk
This question tests understanding of assistive devices and client teaching for wheelchair positioning in children with cerebral palsy. The primary concern is proper footrest adjustment to prevent sliding and maintain posture, reducing pressure sores. Option B is the best choice because supporting thighs and feet flat enhances stability and skin protection, addressing the caregiver's report. Options A, C, and D are less optimal: A hinders access; C and D promote poor positioning. Effective client teaching includes demonstrating adjustments and rationale. A principle of device use is ensuring alignment to distribute pressure evenly. A transferable strategy is to teach caregivers daily positioning checks to prevent complications.
- A 66-year-old client post-stroke uses a cane and is being discharged. The client lives in a home with scatter rugs and a small dog that often runs underfoot. Which discharge teaching is MOST important?
Answer: Remove or secure scatter rugs and keep walkways clear; consider confining the pet during ambulation to prevent tripping
This question tests understanding of assistive devices and client teaching for home safety with canes. The primary concern is modifying the environment to prevent tripping from rugs and pets. Option A is the best choice because securing hazards and managing the pet reduces fall risk during discharge. Options B, C, and D are incorrect: B limits access; C restricts use; and D increases instability. Effective client teaching includes home hazard identification. A principle of device use is environmental compatibility. A transferable strategy is to provide checklists for home safety audits.
- A 76-year-old client post-hip replacement is using a walker and asks how to sit in a chair safely. The client has low muscle strength and a history of falls. Which instruction is MOST important?
Answer: Back up until the legs touch the chair, reach back for the armrests one hand at a time, and lower slowly without holding the walker
This question tests understanding of assistive devices and client teaching for safe sitting with walkers post-hip replacement. The primary teaching point is proper technique to maintain balance with low strength. Option A is the best choice because backing up and using armrests prevents falls without relying on the walker. Options B, C, and D are incorrect: B risks tipping; C promotes haste; and D obstructs. Effective client teaching uses sequential steps. A principle of device use is controlled movements. A transferable strategy is to practice transitions in varied settings.
- A 52-year-old client with amyotrophic lateral sclerosis has worsening hand weakness and uses adaptive utensils. The client says, "I hold the utensil with my fingertips so I can control it better." Which statement indicates a need for further instruction?
Answer: "I should grip the utensil with my fingertips only, even if my hand starts to cramp."
This question tests understanding of assistive devices and client teaching for adaptive utensils in ALS with hand weakness. The primary concern is promoting ergonomic grips to reduce cramping and support feeding. Option C indicates a need for further instruction because fingertip gripping exacerbates cramping, whereas adaptive tools allow better control. Options A, B, and D are appropriate: A conserves energy; B eases grip; and D aids containment. Effective client teaching corrects misconceptions gently. A principle of device use is minimizing strain through modifications. A transferable strategy is to encourage trial and feedback on devices.
- A 29-year-old client with a new prosthetic limb asks how to clean the residual limb and prosthetic liner. The client works construction and sweats heavily. Which teaching is MOST important?
Answer: Wash the residual limb daily with mild soap and water, rinse and dry thoroughly, and clean the liner as directed to reduce skin irritation and infection risk.
The priority is protecting the residual limb from sweat, debris, and bacterial growth, especially in a physically active client. Washing with mild soap and water, rinsing thoroughly, drying the skin, and caring for the liner as directed removes irritants and prevents skin breakdown and infection. The lotion option does not clean the limb; a generous layer kept on before and during wear can trap sweat and moisture under the liner, making it slippery and causing friction. The hot-water option targets the device itself and risks damaging the liner, but it does not attend to the residual limb skin that is actually at risk. Using antibacterial soap and alcohol on the residual limb, then the same alcohol on the liner, is overly harsh: alcohol can dry and irritate the skin and may damage the liner material. Mild cleaning and routine liner care remain the safe, effective teaching.
