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 A

Explanation

The nurse should remove the absorbent pads from underneath the client, place the client in a supine position with arms at the sides, close the client's eyes, and replace the client's dentures.

A pillow may be placed under the client's head for cosmetic purposes, but this is not a necessary action. High-Fowler's position is not appropriate for a deceased client.

A. 2+ pedal edema B. Jaundice C. Nuchal rigidity D. Hematuria

Correct Answer is C

Explanation

Bacterial meningitis is a serious infection of the membranes surrounding the brain and spinal cord that can cause inflammation and damage to the nervous system.

Nuchal rigidity refers to stiffness and pain in the neck that makes it difficult to flex the neck forward. This finding is indicative of inflammation of the meninges and is a classic sign of meningitis.

Pedal edema refers to swelling of the feet and ankles and can be caused by various conditions such as heart, liver, or kidney problems.

Jaundice refers to yellowing of the skin and eyes and can be caused by liver or bile duct disease.

Hematuria refers to the presence of blood in the urine and can be caused by various conditions such as urinary tract infections, kidney stones, or bladder cancer. These findings are not related to bacterial meningitis and may suggest other health concerns that require further evaluation and management.

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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?

Nursing Test Bank

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