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.
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
The client is experiencing palpitations and a sense of impending doom, which may indicate a heightened state of anxiety or a panic attack. Minimizing environmental stimuli can help create a calming and safe environment for the client. By reducing noise, bright lights, and other potentially distressing stimuli, the nurse can create a more soothing atmosphere that may help alleviate the client's anxiety.
While exploring behaviors that have helped to reduce the client's anxiety in the past and explaining to the client that anxiety causes physical manifestations are important actions, they may not provide immediate relief or address the client's immediate distress.
Administering an anti-anxiety medication may be considered if the client's symptoms persist or worsen, but it is not the first action to be taken. The nurse should prioritize non-pharmacological interventions and create a supportive environment before considering medication administration.
Correct Answer is B
Explanation
Veracity refers to the ethical principle of truthfulness and honesty in communication. By communicating truthfully about the adverse effects of the client's prescribed medications, the nurse is practising veracity. This means providing accurate and complete information to the client, enabling them to make informed decisions about their healthcare.
Beneficence refers to the obligation of healthcare professionals to act in the best interests of the client and promote their well-being. While the nurse's actions may align with beneficence by providing information about medication adverse effects, it is specifically veracity that is demonstrated in this scenario.
Justice pertains to fairness and equal treatment. Although important in healthcare, it is not directly related to the nurse's communication of adverse effects.
Autonomy refers to respecting and supporting the client's right to make their own decisions about their care. While the nurse's truthful communication about adverse effects supports the client's autonomy, it is the concept of veracity that specifically addresses honesty and truthfulness in communication.
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