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 C
Explanation
A. Turn on loud music in client care areas: Loud music can increase noise levels, which contributes to environmental stress and can disrupt clients’ rest and recovery. It is generally contraindicated in acute care settings where reducing stress and promoting healing are priorities.
B. Assign different nurses to provide care for clients each day: Frequent changes in caregivers can increase client anxiety and stress by reducing continuity of care and trust. Consistent assignments promote familiarity, comfort, and better communication between clients and caregivers.
C. Restrict the number of visitors for clients: Limiting visitors helps reduce noise and overcrowding, which are common environmental stressors in acute care units. This strategy supports a calmer environment conducive to client rest and recovery while maintaining essential social support.
D. Offer the clients many choices regarding care: While offering choices can promote autonomy, providing too many options may overwhelm clients, especially those who are ill or stressed. Simplifying decisions helps reduce cognitive overload and environmental stress.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
- Aspiration: The client reports food getting stuck in the mouth and has a hoarse voice, which are classic signs of dysphagia (difficulty swallowing). Dysphagia significantly increases the risk for aspiration, where food or liquid enters the airway instead of the esophagus.
- Neurological status: The client also has left-sided weakness, suggesting a neurologic impairment (possibly from a stroke or similar event), which can affect swallowing coordination and airway protection.
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