The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.
Continue PROM if joint's muscle spasms to relax muscle.
Slowly stretch the joint's muscles if pain is present.
Move the joint slowly until resistance is felt.
Instruct the client to relax during the exercises.
Support the extremity of the joint being exercised.
Correct Answer : C,D,E
A. Continue PROM if joint's muscle spasms to relax muscle: Continuing to move a joint during muscle spasms can worsen injury or cause pain. PROM should be stopped if spasms occur and reassessed to prevent harm.
B. Slowly stretch the joint's muscles if pain is present: Stretching a joint when pain is present can cause tissue damage or exacerbate injury. Pain indicates that the joint has reached its limit, so exercises should be within a pain-free range.
C. Move the joint slowly until resistance is felt: Moving the joint slowly until resistance allows for safe assessment of mobility and flexibility without overstretching or causing injury. Resistance provides a natural limit to the joint’s passive range of motion.
D. Instruct the client to relax during the exercises: Relaxation reduces muscle tension, allowing for safer and more effective passive movements. Client cooperation helps prevent muscle guarding and ensures proper joint mobilization.
E. Support the extremity of the joint being exercised: Supporting the extremity prevents undue stress on muscles and joints, reduces the risk of injury, and allows controlled movement during PROM exercises. Proper support is essential for safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maintain strict intake and output: In septic shock, monitoring fluid balance is critical because clients are at high risk for hypovolemia, organ dysfunction, and multi-organ failure. Accurate intake and output measurements guide fluid resuscitation and help evaluate response to therapy.
B. Monitor blood glucose level: Hyperglycemia can occur in sepsis and should be monitored, but it is secondary to maintaining adequate perfusion and fluid balance. Glucose monitoring supports overall care but is not the immediate priority in shock management.
C. Assess warmth of extremities: Extremity warmth or coolness provides information about perfusion and circulatory status but is observational. It does not actively intervene to reverse the pathophysiologic processes of septic shock.
D. Keep head of bed raised 45 degrees: Elevating the head of the bed may reduce aspiration risk, but it does not address the urgent need to manage hypoperfusion, organ perfusion, and fluid status in septic shock.
Correct Answer is C
Explanation
A. "I am happy that you are getting better and will be able to go home.": While positive reinforcement is supportive, it does not address the client’s dichotomous thinking or help them process their perception of the night nurse. It avoids exploring the issue.
B. "Tomorrow I will talk to that nurse about how you were treated last night.": This response reinforces splitting behavior by positioning the nurse as an advocate against a colleague, which may escalate the client’s polarized thinking.
C. "What did the night nurse do that makes you think the nurse is aloof?": This approach encourages the client to reflect on specific behaviors rather than labeling individuals. It helps the client develop insight, reduces dichotomous thinking, and promotes accountability for their perceptions.
D. "I am glad you like me. Which nurse was acting aloof to you?": Combining affirmation with comparison may unintentionally reinforce splitting and favoritism, maintaining the client’s black-and-white perception of others. It does not encourage reflective thinking.
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