A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

A) Muscle mass:
Passive range of motion (ROM) exercises do not directly increase muscle mass. These exercises primarily help maintain joint function and flexibility rather than build muscle tissue, which requires active resistance exercises and strength training.

B) Bone density:
While weight-bearing activities can help improve bone density, passive ROM exercises do not have a significant impact on bone density. Passive ROM helps preserve joint function and flexibility but does not address the strengthening of bones.

C) Joint flexibility:
Passive ROM exercises are specifically designed to improve and maintain joint flexibility. These exercises involve the nurse or caregiver moving the client’s joints through their full range of motion without the client’s active participation. The goal is to maintain or increase the joint's flexibility and prevent stiffness, especially in patients who are unable to move their limbs actively, such as those who have had a stroke.

D) Muscle strength:
Passive ROM does not increase muscle strength because the client is not actively engaging their muscles. Muscle strength is built through active movements or resistance exercises, where the client’s muscles work against a force. Passive ROM helps maintain joint mobility, not muscle strength.

A) Planning:
The step of the nursing process where the nurse formulates goals to address an identified problem is planning. In this phase, the nurse develops a care plan by setting measurable and achievable goals based on the assessment data. These goals are designed to address the specific health problems identified during the assessment phase. The planning stage also involves determining appropriate interventions and establishing expected outcomes for the patient. It's critical to ensure that the goals are realistic and aligned with the patient’s needs and preferences.

B) Implementation:
Implementation refers to the actual carrying out of the nursing interventions and care plan that were developed during the planning phase. This is when the nurse takes action based on the goals set earlier, such as administering medications, teaching the patient, or performing specific procedures. While this phase is crucial for the success of the care plan, it does not involve the creation of goals, which is the focus of the planning phase.

C) Assessment:
Assessment is the first step in the nursing process. It involves gathering comprehensive information about the patient’s physical, psychological, social, and emotional status. The assessment phase is focused on identifying the patient’s needs, strengths, and problems. While it provides the foundation for formulating goals, it is not the phase where goals are set. Instead, the assessment phase is about collecting data to inform the planning process.
D) Evaluation:
Evaluation occurs after the implementation of interventions. During this phase, the nurse evaluates whether the patient’s goals have been met, partially met, or not met at all. The nurse examines the effectiveness of the care plan and determines if adjustments need to be made. This is not the phase where goals are set; rather, it is a reflective stage where the nurse assesses progress toward achieving the goals established in the planning phase.