A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?
Move body parts rapidly through the movements.
Support extremities above and below joints.
Continue moving body parts if muscle spasticity occurs.
Stretch the body part just beyond the existing range of motion.
The Correct Answer is B
A. Move body parts rapidly through the movements. Passive range of motion (ROM) should be performed slowly and gently to prevent injury or pain.
B. Support extremities above and below joints. Supporting both above and below the joint helps prevent excessive strain and allows for controlled movement.
C. Continue moving body parts if muscle spasticity occurs. If muscle spasticity occurs, the nurse should stop and reassess before continuing, to avoid injuring the client.
D. Stretch the body part just beyond the existing range of motion. The nurse should never push beyond the client’s normal range, as this can cause pain or injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Identify when the client first noticed the lesion. Determining onset and duration helps assess whether the lesion is new, growing, or concerning for malignancy.
B. Photograph the lesion for the client's medical record. While documentation is important, assessing history and changes in the lesion takes priority.
C. Instructing the client on the use of daily sunscreen products. Sunscreen is essential for prevention, but identifying and assessing the lesion comes first.
D. Document the client's history of skin allergies. While important, it does not take priority over determining how long the lesion has been present and whether it is changing.
Correct Answer is B
Explanation
A. Move body parts rapidly through the movements. Passive range of motion (ROM) should be performed slowly and gently to prevent injury or pain.
B. Support extremities above and below joints. Supporting both above and below the joint helps prevent excessive strain and allows for controlled movement.
C. Continue moving body parts if muscle spasticity occurs. If muscle spasticity occurs, the nurse should stop and reassess before continuing, to avoid injuring the client.
D. Stretch the body part just beyond the existing range of motion. The nurse should never push beyond the client’s normal range, as this can cause pain or injury.
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