basic care & comfort

Question 1

explain 2 point gait, 3 point gait, four point gait

Answer 1

two point gait: can bear at least partial weight on both legs
fourth point gait: can bear weight on both legs

three point gait: CANNOT bear weight on the affected leg, 3 is inferior, hence why I cannot pronounce it, I cannot bear it

Question 2

Explain the process when going up the stairs w/ crutches

Answer 2

good leg up, bad leg down.

good leg up first, then crutches are more helpful than cane if you have more problems, etc.. not able to bear weight
two point gait, three point gait, 4 point gait

Question 3

right leg is affected

move non-affected leg first w/ crutch on the affected side. so that you can move the
crutch on the (non-injured side) and right leg (injured) together, this is to support the affected leg

which gait is this call?

Answer 3

two point gait
(opposite attracts), leg and crutch opposites

Question 4

move crutch (on injured side) then move non-injured foot, then move the injured crutch then the non-injured foot

Answer 4

four point gait
everything move separelety
separetely slow

Question 5

move both crutches together and injured leg at the same time, then move non-injured leg after

Answer 5

3 point gait, cannot bear weight on affected leg

Question 6

swing gait

Answer 6

move both crutches then move both legs, can bear weight on both

Question 7

swing through gait

Answer 7

they move crutches first then legs but legs pass the crutches

can use w/ non weight bearing, but three point gait is better

Question 8

going up the stairs w/ crutches

Answer 8

good up, bad down

good leg goes up first (good leg doesn’t need crutches) on the stairs. followed by both crutches, then the bad leg

Question 9

when going down the stairs w/ crutches

Answer 9

move the crutches down, follow by the bad leg, the
move the good leg goes down onto the step

Question 10

how a pt sits up & down w/ crutches

Answer 10

to sit
back up to chair
put non-injured leg on chair
move both crutches on the side for support.
hold hand grip, slightly bend non-injured leg and keep injured leg extended

Question 11

to get up in a chair w/ crutches

Answer 11

take crutches and put on injured side for support
keep injured leg extended
push ups on non-injured side and using hand grip of crutches, then put crutches in position

Question 12

cane

Answer 12

for the 1st time, cane has to be adjusted
cane should be even w/ the wrist crease t
elbow should be flex at 15 - 30 degrees angle

wear a gait belt for safety
*Stand on the patient’s weak side, in case they lose their balance
position the tip of cane at least 4 inches on side of foot.
*hold cane on STRONG side of body
how to ambulate
move cane w/ the weak side together forward, then move the strong side forward

going up stairs w/ cane: put cane on good side. good leg up, then cane and bad leg together.
going down: put bad leg down together w/ the cane (put on strong side), then move the good leg onto the steps

Question 13

rubber tips on crutches provide traction and stability, they should not be remove b/c it inc. risk of

Answer 13

slipping and falling. so keep rubber tips on

Question 14

onchia

Answer 14

inflammation of nail beds

Question 15

explain procedure before filling/priming enema bag b/c remember pt can refuse, so gotta explain first

Question 16

stomach that appears concave/bowl shape

Answer 16

a stomach that has retracted

Answer 17

stoma should pinkish, red, and moist

dry, dusky, reddish/purplish: ischemia

narrow, flattened, constricted indicates stenosis

Question 18

pt that have difficulty swallowing can have —- diet

Answer 18

soft diet
as well as clear liquid, full liquid

Question 19

2-3 finger weath should be b/w the crutch and the clients axilla
can axilla support body weight

Answer 19

no, can cause injury

Question 20

how to sit down with a cane

Answer 20

back up a chair until you fill your legs in the chair. put cane on the side. place both hands on armrest and use arms to sit down.

to get up: take cane put in strong cane near strong leg
put weight on strong leg

Question 21

walkers

Answer 21

proper fit, the gait
adjust walkers.
15 - 30 degrees bend in elbow
wrist crease should line up to hand grips

what to move first?
for safety, apply a gait belt. stand on pt’s weak side in case they stumble or fall?
tell them to not stare down at their feet, look straight ahead

1. hold on to handgrips of the walker
2. lift and move the walker forward
3. move weak side, put weight on both hands
4. move strong side

Question 22

when a patient dies, the goal is not to do oral care or hygiene, but to prevent discoloration of face for family viewing.

Answer 22

oral care is not indicated in post-moterm care.

Question 23

when cleaning catheter care, use warm water. I selected hot in of the quizzes. which doesn’t make sense. that’s not comfortable for the patient.

Answer 23

and also while cleaning, ensure that the tubbing is clipped, to prevent the bag from moving, and to prevent trauma on the urinary tract.

make sure tubing is not kinked though

Question 24

foods that are high in calcium are low in

Answer 24

phosphorus.

phosphorus goes opposites of calcium
so foods low in phosphorus will be: leafy greens like spinach, kale, milk, etc..

foods high in phosphorus are: garlic, nuts, turkey

Question 25

what’s the best way to assess for fall risk
is it self report or observing the client’s gait?

Answer 25

observing the client’s gait and balance
the client might say they don’t have fall risks (maybe b/c they don’t wanna be monitor), but in reality they do.

Question 26

log rolling
how many staff can do it

Answer 26

use to keep spinal column straight to prevent injury. use for clients receovering or have spinal cord injury

a minimum of 3 people
cross the clients arm on their chest
shoulders & hips rolls at the same time
fan fold draw sheet along the backside of client
its safe to put pillow in between
1 nurse will stay by the client’s head for safety

document the log rolling procedure in the client’s record.

Question 27

chlorhexidine what is it for and how to apply it?

Answer 27

chlorhexidine is an antimicrobial agent that inhibit bacterial growth for 24hrs. the solution should not be RINSED off. will be sticky, that means its been applied correctly and will be effective

its a good tool to prevent surgical site infection & hospital acquired infections. can be done using wipes or solution in a bottle.
use one cloth for each body part
don’t dip used cloth back into the solution
a sticky residue is expected and will lessen, do not rinse off.

chg is safe to use on the perineum and external mucosa. but its best to clean this area with soap and water

Question 28

how much should elbow be flexed when using crutches

Answer 28

elbow should be flexed to 30 degrees.
use hand and arms to support body weight

Question 29

children have to stay in the back until they are —- years old.

0 - 2 years old are —front or rear— facing
2+ years old are —- facing

Answer 29

back seat until they’re teenagers, 13yrs old.
0-2 rear facing, younger children are rear facing

2+ are front facing

chest clip at armpit level or breast bone
its ok to add padding behind the child’s back.