A nurse is assessing a client in high-Fowler's position for signs of skin breakdown. Which areas should the nurse assess first?

A. Range of motion that is performed by a healthcare provider: This describes passive range of motion, where the provider moves the client’s joints without active muscle contraction by the client. It is used when clients are unable to move independently.

B. Range of motion that is performed by the client: Active range of motion involves the client voluntarily moving their joints through the full available range. This type of exercise maintains joint flexibility, promotes circulation, and helps preserve muscle strength.

C. The maximum range of motion of healthy joints: While active ROM may approach normal joint limits, it is defined by voluntary movement, not solely by joint health. Maximum joint capacity is not part of the operational definition.

D. An exercise that increases muscle strength and joint mobility: Active ROM may improve circulation and maintain flexibility but does not necessarily significantly increase muscle strength. Strengthening exercises often require resistance beyond active joint motion alone.

A. Kussmaul respirations: These are deep, rapid, and labored respirations typically associated with metabolic acidosis, such as diabetic ketoacidosis. They do not include alternating periods of apnea and hyperventilation, so they do not match the described pattern.

B. Cheyne-Stokes respirations: This breathing pattern is characterized by cyclic periods of increasing and decreasing depth of respiration, followed by temporary apnea. It commonly occurs in clients with advanced heart failure, neurological injury, or nearing end-of-life, making it consistent with hospice clients exhibiting irregular breathing.

C. Agonal breathing: Agonal respirations are irregular, gasping breaths often seen in severe hypoxia or near death. They are typically ineffective for gas exchange and not part of a regular cyclical pattern.

D. Biot's respirations: Biot’s respirations consist of groups of quick, shallow breaths followed by irregular pauses. They are usually associated with increased intracranial pressure or medullary damage rather than end-of-life breathing patterns.