A nurse is reinforcing teaching about passive range-of-motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching?

Support the extremity above and below each joint during the exercises.

Repeat each exercise movement 10 times.

Position the bed at mid-thigh level.

Move each joint just past the point of resistance.

Answer and Explanation

The Correct Answer is A

This is an essential instruction for performing passive ROM exercises safely and effectively. Supporting the extremity above and below each joint helps to prevent injury and provides stability during the exercise. This technique also helps to minimize discomfort and maintain proper alignment of the joint.

Repeat each exercise movement 10 times: This instruction does not provide sufficient guidance on the number of repetitions and may be too general. The number of repetitions will depend on the client's condition and tolerance.

Position the bed at mid-thigh level: This instruction is not necessary for performing passive ROM exercises and may not be feasible in all settings.

Move each joint just past the point of resistance: This instruction can be harmful and may cause injury or pain. The nurse should encourage the family to move the joint gently and smoothly, within the range of motion that is comfortable for the client.

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Correct Answer is C

Explanation

Assessing the client's ability to use the call light is crucial for their safety and well-being. If the client is unable to use the call light to request assistance, it increases the risk of falls or accidents when they attempt to move or perform tasks without assistance. By determining the client's ability to use the call light, the nurse can ensure that appropriate measures are in place to enable the client to call for help whenever needed.

Applying rubber-soled slippers before ambulation helps to provide better traction and reduce the risk of slips and falls, but it can be implemented after assessing the client's ability to use the call light.

Moving the bedside table closer to the bed is helpful for the client to access personal items without the need to reach or stretch, but it is not the highest priority among the given options.

Creating a schedule with assistive personnel for hourly rounding is important for regular checks on the client's safety and well-being, but it can be arranged after assessing the client's ability to use the call light.

A. "I should not feed my baby anything for 2 hours prior to an immunization." B. "I should expect my baby to have a high fever for 24 hours after an immunization." C. "My baby will receive the rotavirus immunization orally D. "My baby will receive three doses of the meningococcal immunization before kindergarten."

Correct Answer is C

Explanation

The rotavirus vaccine is administered orally, usually in the form of drops. It is given to infants to protect against rotavirus, which is a common cause of severe diarrhea and dehydration in young children. By stating that the baby will receive the rotavirus immunization orally, the guardian demonstrates an understanding of this specific vaccination.

There is no need to restrict feeding for a specific duration before immunization unless otherwise specified by the healthcare provider. In general, it is important to ensure that the infant is well-fed and hydrated.

While mild side effects such as low-grade fever, fussiness, or local soreness at the injection site may occur after immunizations, having a high fever for 24 hours is not a typical or expected reaction. If a high fever or any concerning symptoms develop after immunization, it is important to contact the healthcare provider.

The number of doses and the schedule for meningococcal immunization can vary depending on the specific vaccine used and the recommendations of the healthcare provider or local guidelines.

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A nurse is reinforcing teaching about passive range-of-motion exercises with the family of a client who has had a stroke. Which of the following instructions should the nurse include in the teaching?

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