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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Administer intravenous antibiotic: Antibiotics are often given as part of appendicitis management, but sudden pain relief may indicate appendix rupture. At this point, the priority is rapid surgical intervention, not antibiotics alone.

B. Place in high Fowler's position: Positioning may help with comfort but does not address the urgent complication of a possible perforated appendix. It is a supportive measure, not a definitive response to the change in symptoms.

C. Determine last dose of analgesic: While it is important to know when pain medication was last administered, relying on this alone could delay recognition of a surgical emergency. Sudden absence of pain in appendicitis is rarely due to analgesia but often due to perforation.

D. Prepare for emergency surgery: A sudden decrease in pain in appendicitis is concerning for rupture, as pressure is relieved when the appendix bursts. This is a life-threatening complication requiring immediate surgical evaluation and intervention.

A. "You should not worry about the growth tables. They are only averages for children." B. "Haven't you been feeding according to recommended daily allowances for children?" C. "Does your child seem mentally slower than his peers also?" D. "The smaller size is probably due to the heart disease."

Correct Answer is D

Explanation

A. "You should not worry about the growth tables. They are only averages for children.": Growth charts are standardized tools used to compare a child’s development with expected norms. Dismissing the concern overlooks an important clinical sign and fails to address the parent’s valid question.

B. "Haven't you been feeding according to recommended daily allowances for children?": This response places blame on the parent and does not acknowledge the child’s medical condition. It may also create unnecessary guilt rather than offering supportive education.

C. "Does your child seem mentally slower than his peers also?": Asking about developmental delay in this way is inappropriate and insensitive. It shifts the focus to cognitive ability rather than addressing the physical growth concern directly tied to the child’s condition.

D. "The smaller size is probably due to the heart disease.": Children with congenital heart defects often experience poor growth because of increased metabolic demands and reduced energy available for growth. This response gives the parent a clear, accurate explanation while validating the concern.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admitted with a diagnosis of appendicitis calls the nurse and states, "Do you think I'll still need surgery? My pain suddenly stopped, and I feel much more comfortable now when I bend my knees." Which action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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