A nurse is preparing to perform passive range of motion exercises for a client who is immobile. Which of the following actions should the nurse plan to take?
Repeat each exercise 10 times.
Increase flexion during a muscle spasm.
Support each extremity above and below the joint.
Move the joint just past the point of resistance.
The Correct Answer is C
A. Repeat each exercise 10 times: Performing passive range of motion exercises 3 to 5 times per joint is usually enough to maintain joint flexibility and prevent stiffness. Repeating the exercises excessively may cause muscle fatigue or irritation, especially in immobile clients. The goal is to promote mobility without causing discomfort or harm.
B. Increase flexion during a muscle spasm: Forcing movement during a muscle spasm can increase pain and potentially cause injury to muscles or joints. The nurse should gently stop the exercise when a spasm occurs and allow the muscle to relax before continuing. Careful, slow movements help prevent exacerbation of muscle spasms.
C. Support each extremity above and below the joint: Supporting the extremity above and below the joint stabilizes the joint and surrounding tissues, reducing the risk of injury during passive movement. This technique also helps control the movement and minimizes discomfort for the client. Proper support is essential for safe and effective passive range of motion exercises.
D. Move the joint just past the point of resistance: Moving a joint beyond the point of resistance can cause tissue damage, pain, and joint injury. The nurse should stop movement at the point of resistance or the onset of discomfort, never forcing further motion. Respecting this limit preserves joint integrity and client safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I should stop receiving Papanicolaou tests once I reach menopause”: Discontinuing Pap tests solely based on menopause is not recommended. Screening continues until at least age 65, depending on the individual's health history and prior screening results. Regular cervical cancer screening is important for early detection, even after menstruation stops.
B. "I might have headaches due to a decline in my estrogen levels”: Fluctuating and declining estrogen levels during perimenopause can trigger headaches or worsen existing ones. Hormonal changes affect blood vessels and neurotransmitters, contributing to the development of migraines or tension headaches in many women during this stage.
C. "The best time to perform a breast self-examination is on the first day of my period”: The ideal time is 7 to 10 days after the start of the menstrual period, when hormonal influence on breast tissue is minimal. Performing it on the first day of menstruation may result in increased tenderness and swelling, making it harder to detect abnormalities.
D. "I can expect to have regular periods until I am in menopause.": Perimenopause is typically marked by irregular menstrual cycles due to hormonal shifts. Periods may become lighter, heavier, more or less frequent before stopping altogether.
Correct Answer is D
Explanation
A. Increase in protein requirements: Protein needs may slightly increase with age to maintain muscle mass, but this does not directly cause weight gain. Instead, inadequate protein may contribute to muscle loss.
B. Increase in fluid requirements: Older adults typically have decreased thirst sensation, not increased fluid needs. Weight gain is not directly linked to hydration needs but more to energy balance.
C. Decrease in vitamin intake: While older adults may have reduced vitamin intake due to dietary changes, this affects micronutrient status rather than causing significant weight gain.
D. Decrease in muscle mass: Sarcopenia, the loss of muscle mass with aging, lowers basal metabolic rate. This decreases calorie expenditure, making it easier to gain weight even with unchanged food intake.
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