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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Explain that the treatment is both safe and therapeutic: Providing reassurance about the safety and effectiveness of the procedure may be informative, but it can unintentionally pressure the client to consent. It does not respect the client’s autonomy or support their right to make independent healthcare decisions.

B. Tell the client that the procedure is necessary: Telling the client a procedure is necessary can sound coercive and may disregard their legal and ethical right to refuse treatment. Nurses must prioritize respecting the client's decisions, even if those decisions involve refusing recommended medical care.

C. Notify the client's loved ones of the client's refusal of the procedure: Informing family members without the client’s consent may breach confidentiality and is not appropriate unless the client is unable to make informed decisions. Client autonomy must be preserved, and their refusal should be respected unless there is an immediate risk of harm.

D. Inform the client they have the right to refuse treatment: Clients have the legal and ethical right to refuse any medical intervention, even if it is life-sustaining. The nurse’s role includes advocating for the client’s autonomy, ensuring informed consent, and supporting their decision without judgment or pressure.

A. Testicular examination B. Colonoscopy C. Clinical breast examination D. Fasting blood glucose

Correct Answer is B

Explanation

A. Testicular examination: Testicular cancer screening is typically encouraged from adolescence to around age 35, as it is more common in younger men. Routine testicular exams are not specifically recommended starting at age 50.

B. Colonoscopy: Colorectal cancer screening, such as colonoscopy, should begin at age 45 or 50 for individuals at average risk. It is a key preventive measure for detecting colorectal cancer in its early stages.

C. Clinical breast examination: Clinical breast exams may be done earlier, typically starting in the 20s or 30s, depending on risk factors. They are not newly initiated at age 50.

D. Fasting blood glucose: Screening for diabetes may begin as early as age 35 in adults with risk factors. It is important but not specifically recommended as a new screening starting at age 50.

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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?

Nursing Test Bank

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