A nurse is collecting data about a client’s range of motion. Which of the following instructions should the nurse give to the client to observe the elbow rotate for supination?
“Turn each of your hands and forearms so your palm is facing down.”
“Take each of your hands and touch your shoulders.”
“Turn each of your hands and forearms so your palm is facing up.”
“Move each of your arms to rest at your sides.”
The Correct Answer is C
A. “Turn each of your hands and forearms so your palm is facing down.”
This describes pronation, not supination. In pronation, the palm faces down, and the radius crosses over the ulna.
B. “Take each of your hands and touch your shoulders.”
This describes flexion at the elbow joint, not supination. Flexion involves decreasing the angle between body parts.
C. “Turn each of your hands and forearms so your palm is facing up.”
This is the correct choice. Supination involves turning the hands and forearms so that the palms face up, and the radius and ulna are parallel.
D. “Move each of your arms to rest at your sides.”
This describes adduction, bringing the arms back to the sides of the body, not supination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tenting
Tenting refers to the delayed recoil of the skin when pinched. In a dehydrated state, the skin loses elasticity, leading to tenting due to decreased skin turgor. This is a specific sign of fluid-volume deficit.
B. Protruding eyeballs
Protruding eyeballs are not typically associated with dehydration. This could be related to other conditions such as thyroid dysfunction, but it is not a specific indicator of fluid-volume deficit.
C. Elevated blood pressure
Elevated blood pressure is not a typical sign of dehydration. In fact, dehydration often leads to a decrease in blood pressure due to reduced blood volume.
D. Dry mucous membranes
Dry mucous membranes can be an indication of dehydration, but in the context of the question, tenting (Option A) is a more specific sign related to skin turgor and is commonly assessed when evaluating for dehydration.
Correct Answer is B
Explanation
A. Rub the client’s feet briskly for several minutes.
Rubbing the feet briskly may not be appropriate for a client with vascular occlusion. Vigorous rubbing could potentially cause damage to already compromised blood vessels, and the increased friction may not be well-tolerated.
B. Obtain a pair of slipper socks for the client.
Providing slipper socks is a non-invasive and appropriate measure to help keep the client's feet warm. Slipper socks can offer comfort without the need for vigorous interventions or potential harm. They provide insulation and can be easily applied.
C. Increase the client’s oral fluid intake.
While staying well-hydrated is generally important for overall health, increasing oral fluid intake may not directly address the specific issue of cold feet associated with vascular occlusion. It is essential to address the underlying circulatory issue causing the symptom.
D. Place a moist heating pad under the client’s feet.
Applying heat, especially in the form of a moist heating pad, may not be recommended for a client with vascular occlusion. Heat can dilate blood vessels and potentially exacerbate the issue by increasing blood flow to the compromised extremity. It's important to avoid interventions that could worsen the vascular compromise.
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