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. Assess the level of consciousness and vital signs for both clients: Assessing vital signs and mental status identifies immediate changes in condition, particularly in critically ill clients. This is a priority because it helps detect life-threatening complications early.
B. Review the plan of care and the medications that are due for both clients: While important for planning interventions, reviewing the plan does not address immediate client safety and physiological status, which takes priority.
C. Complete a head-to-toe assessment of the client with pneumonia: A comprehensive assessment is valuable, but initial priority is rapid evaluation of vital signs and consciousness to identify urgent issues in the mechanically ventilated client.
D. Change the surgical dressing to observe the appearance of the incision: Dressing changes are important for infection prevention, but they are not emergent unless there are signs of acute bleeding or infection. Immediate physiologic assessment takes precedence.
Correct Answer is ["B","C"]
Explanation
A. Tremors: Benztropine is an anticholinergic used to reduce tremors in Parkinson’s disease, so tremors are not an expected adverse effect of this medication.
B. Urinary retention: Anticholinergic effects of benztropine can decrease bladder contractility, leading to urinary retention, which is a common side effect that clients should monitor.
C. Blurred vision: Benztropine can cause blurred vision due to its anticholinergic effect on the eyes, including pupillary dilation and impaired accommodation. Clients should be cautioned about visual changes.
D. Diarrhea is uncommon with benztropine; in fact, anticholinergic medications more often cause constipation rather than diarrhea.
E. Drooling: Benztropine reduces salivation, so drooling is not expected. The medication may actually help decrease excessive salivation associated with Parkinson’s disease.
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