A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms should the nurse use when documenting the client making a fist with her hand?

Flexion

Adduction

Extension

Abduction

Answer and Explanation

The Correct Answer is A

A. Flexion refers to decreasing the angle between two body parts. Making a fist involves bending the fingers toward the palm, which is flexion.
B. Adduction refers to moving a body part toward the midline of the body, which does not describe making a fist.
C. Extension is the opposite of flexion, increasing the angle between body parts; opening the hand from a fist would be extension.
D. Abduction is moving a body part away from the midline, which does not describe making a fist.

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Correct Answer is B

Explanation

A. Cool toes indicate impaired circulation, but this usually occurs after edema develops.
B. Edema of the toes is often the first sign that a cast is too tight, as swelling occurs distal to the cast and may progress to compromise circulation and nerve function.
C. Inability to move toes is a later sign indicating severe neurovascular compromise.
D. Pallor also indicates compromised circulation, which occurs after swelling has already begun.

A. Drink at least 2 L (66.7 oz) of water per day. B. Use a commercial mouthwash after each meal. C. Take the medication every day. D. Avoid eating foods high in vitamin K.

Correct Answer is A

Explanation

A. Methotrexate can cause renal toxicity. Encouraging fluid intake of at least 2 L/day helps prevent kidney damage and promotes drug excretion, making this the correct instruction.
B. Commercial mouthwashes often contain alcohol, which can worsen methotrexate-induced stomatitis. Instead, clients should use a soft toothbrush and nonalcoholic rinses.
C. Methotrexate for rheumatoid arthritis is taken weekly, not daily. Daily dosing can lead to severe toxicity.
D. Foods high in vitamin K affect warfarin therapy, not methotrexate. There is no restriction on vitamin K with methotrexate use.

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A nurse is assisting a client with range-of-motion exercises of the hands and wrists. Which of the following terms should the nurse use when documenting the client making a fist with her hand?

Nursing Test Bank

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