A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

Abduction

External rotation

Internal rotation

Adduction

Answer and Explanation

The Correct Answer is A

A. Abduction:

Abduction refers to movement of a limb away from the midline of the body, such as raising the arm from the side outward and upward.

B. External rotation:

This refers to rotating a limb outward along its axis, not raising the arm overhead.

C. Internal rotation:

This refers to rotating the limb inward, which is not the action of lifting the arm above the head.

D. Adduction:

Adduction refers to moving a limb toward the midline, the opposite of abduction.

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Correct Answer is B

Explanation

A. Reassess the area in 8 hours

Delaying action may result in wound dehiscence or further tissue damage.

B. Stop the machine and notify the primary care provider

Signs of wound stress (opening, tightness) require immediate discontinuation of the CPM and notification of the provider to prevent further damage.

C. Increase the angle of the flexion of the joint to change the pressure on the heel

Increasing the angle may worsen the wound separation and increase pressure on the incision.

D. Pad the portion of the machine that the heel rests on

Padding may prevent pressure injury but does not address the wound issue or tightness from movement.

A. "Keep your head straight and turn it as far as possible to either side." B. "Move your head from the upright position back as far as you can." C. "Move your head so that your chin rests on your chest." D. "Move your head laterally towards your right and left shoulder."

Correct Answer is B

Explanation

A. "Keep your head straight and turn it as far as possible to either side."

This is rotation, not hyperextension.

B. "Move your head from the upright position back as far as you can."

This describes hyperextension, which is the movement of the head beyond the neutral upright position.

C. "Move your head so that your chin rests on your chest."

This is flexion, not hyperextension.

D. "Move your head laterally towards your right and left shoulder."

This describes lateral flexion, not hyperextension.

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A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

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