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 ["A","B","C","D"]
Explanation
A. Amount of time washing hands: The client increased handwashing time to 15 seconds, which meets the CDC’s recommended minimum for effective hand hygiene when preparing food.
B. Use of cutting board: The client now uses separate cutting boards for raw meats and raw vegetables, which helps prevent cross-contamination and foodborne illness.
C. Defrosting of frozen foods: Defrosting foods in the refrigerator is a safe method that prevents bacterial growth, unlike leaving food on the countertop.
D. Leftover storage time in refrigerator: Storing leftovers in the refrigerator for a maximum of 2 days (or 7 days initially) demonstrates proper food handling to prevent spoilage and bacterial growth.This aligns with recommended guidelines.
E. Refrigerator temperature: Although the temperature has improved (now 5.6°C instead of 6.7°C), the ideal refrigerator temperature should be 4°C (40°F) or lower for optimal food safety.
F. Time leftovers sit unrefrigerated on countertop: Leaving leftovers at room temperature for 2 hours still meets the maximum allowable limit, but best practice is to refrigerate within 1 hour if the room temperature is high (above 90°F/32°C), which might not reflect consistent safe food handling in all conditions.
Correct Answer is A
Explanation
A. Instruct the client to blink his eyes as a response: Expressive aphasia affects a person's ability to speak or write, but comprehension is often intact. Encouraging nonverbal communication methods such as blinking for "yes" or "no" responses can help the client effectively express needs and participate in care decisions without requiring speech.
B. Increase voice volume when speaking to the client: Raising the volume does not assist clients with expressive aphasia, as their difficulty lies in expression rather than hearing. Speaking louder can be perceived as frustrating or disrespectful and may not improve understanding or communication for the client.
C. Avoid using hand gestures: Hand gestures and facial expressions can enhance communication for individuals with aphasia by providing visual cues. Avoiding gestures removes a valuable tool that may help the client interpret and respond to messages, especially when they cannot verbalize thoughts.
D. Enunciate words slowly: While speaking clearly is beneficial in many communication disorders, expressive aphasia primarily impairs output, not comprehension. Enunciating slowly may not help the client respond more effectively and is more useful in receptive or global aphasia cases.
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