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A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?
- A. Splint the joint and continue passive range of motion to the shoulder only.
- B. A passive range of motion to the right elbow and the right knee back to the right.
- C. Apply weights to the right distal extremity before initiating any joint exercise.
- D. Continue to move the joint only to the point at which resistance is met.
Correct Answer: D
Rationale: Moving a joint beyond the point at which the client feels pain or resistance can damage the joint. The nurse should move the joint only to the point of resistance to prevent injury. Splinting the joint will not assist the client's range of motion and may restrict it further. The option of passive range of motion to the elbow and knee is unclear and not a standard practice. Applying weights to the extremity will not increase range of motion and could cause harm.
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A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?
- A. Passive range of motion
- B. Active range of motion
- C. Resistive range of motion
- D. Aerobic exercise
Correct Answer: B
Rationale: Active range of motion exercises promote strength, range of motion, and independence with activities of daily living, making them appropriate for a client with generalized weakness. Passive range of motion is suitable for clients unable to move independently, resistive range of motion may be too strenuous, and aerobic exercise may not directly address the client's need for improved daily function.
A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this client's risk of fracture?
- A. Apply shoes to improve foot support.
- B. Perform weight-bearing activities.
- C. Increase calcium-rich foods in the diet.
- D. Use pressure-relieving devices.
Correct Answer: B
Rationale: Weight-bearing activity reduces bone mineral loss and promotes bone uptake of calcium, decreasing the risk of fractures in clients with decreased mobility. While increasing calcium-rich foods is beneficial for bone health, it alone will not sufficiently reduce fracture risk. Foot support and pressure-relieving devices help with mobility and skin integrity but do not directly address bone strength or fracture prevention.
A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?
- A. Nutritional intake and serum albumin levels
- B. Pressure ulcer diameter and depth
- C. Wound drainage, including color, odor, and consistency
- D. Dressing site and antibiotic ointment application
Correct Answer: A
Rationale: Assessing nutritional intake and serum albumin levels helps determine the client's nutritional status, which is critical for preventing pressure ulcers, as poor nutrition can impair skin integrity. The other options focus on treating existing pressure ulcers rather than preventing their formation.
A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?
- A. Insert an indwelling urinary catheter.
- B. Stroke the medial aspect of the thigh.
- C. Use the Credé maneuver every 3 hours.
- D. Apply a Texas catheter with a leg bag.
Correct Answer: C
Rationale: The Credé maneuver, which involves applying manual pressure to the bladder, can facilitate voiding in clients with a flaccid bladder due to a spinal cord injury at T3. Indwelling catheters increase the risk of urinary tract infections and are generally avoided. Stroking the medial thigh is used for upper motor neuron issues, not flaccid bladders. A Texas catheter is unsuitable as the client may be unaware of a full bladder and unable to control voiding.
A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the client's activity violence?
- A. Vital signs before, during, and after activity
- B. Body image and self-care abilities
- C. Vital signs use and self-care device devices
- D. Clients electrocardiography readings
Correct Answer: A
Rationale: To see whether a client is tolerating activity, vital signs are measured before, during, and after the activity. If the client is not tolerating activity, heart rate may increase more than 20 beats/min, blood pressure may increase more than 20 mmHg, or the client may experience symptoms indicating intolerance. Body image assessment is not necessary before basic activities are performed. Self-care abilities and ability to use assistive or adaptive devices are important when planning rehabilitation activities but do not provide essential information about activity tolerance. Electrocardiography is not typically used to monitor clients in a rehabilitation setting for activity tolerance.