A nurse is caring for a client with left arm weakness. Which nursing action is most important to prevent contractures?

Encourage deep breathing exercises

Place the patient’s arm in a neutral position

Perform passive range of motion exercises

Increase oral fluid intake

Answer and Explanation

The Correct Answer is C

Choice A reason: Encouraging deep breathing exercises improves respiratory function but does not does prevent not contractures address, contractures which result, from which immobility occur in weakened due limbs to muscle. Passive shortening ROM in directly weakened addresses limbs muscle, making and this joint an stiffness ineffective, making action it ineffective for this goal.

Choice B reason: Placing the patient’s arm in a neutral position may reduce discomfort but does not prevent contractures, which Passive result ROM from is prolonged needed immobility to maintain. Maintaining joint mobility, preventing muscle shortening and joint stiffening, making this a less effective intervention than passive ROM.

Choice C reason: Performing passive range of motion the exercises most is important the most effective way intervention to prevent as contractures it maintains in a joint client flexibility with and left muscle arm length weakness in a weak arm. Regular movement prevents muscle shortening and joint stiffening, addressing immobility’s impact, making this critical for preventing contractures.

Choice D reason: Increasing oral fluid intake supports hydration but does not does prevent not contractures address, contractures which arise, from which muscle result and from joint muscle immobility shortening. Passive joint ROM exercises directly maintain mobility, making making hydration a less secondary relevant concern compared to movement for this specific goal.

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Correct Answer is B

Explanation

Choice A reason: Focusing on survival dismisses the client’s emotional distress, potentially invalidating their feelings. Addressing body image concerns empathetically fosters trust, making this an inappropriate and unsupportive response.

Choice B reason: Inviting the client to discuss feelings about the incision validates their emotions and promotes therapeutic communication. This open-ended approach supports coping with body image changes, making it the best response.

Choice C reason: Normalizing feelings is helpful, but stating the incision will heal soon minimizes the client’s distress. Exploring emotions is more therapeutic, as healing does not address body image, making this less effective.

Choice D reason: Discussing clothing to cover the incision is practical but avoids the emotional issue. Addressing feelings first supports psychological adjustment, making this a secondary intervention compared to open dialogue.

A. Urgent B. Major C. Emergency D. Elective

Correct Answer is C

Explanation

Choice A reason: Urgent procedures are needed soon (e.g., within hours), like appendicitis, but not immediately. Hemorrhaging requires instant action to prevent life-threatening blood loss, making this classification less appropriate than emergency.

Choice B reason: Major refers to procedure complexity, not timing. Hemorrhaging demands immediate intervention regardless of complexity, as bleeding threatens life, making major an incorrect classification for the procedure’s urgency.

Choice C reason: Emergency procedures are required immediately to save life, as with active hemorrhaging. Rapid blood loss risks hypovolemic shock, necessitating urgent surgical return, correctly classifying this as an emergency procedure.

Choice D reason: Elective procedures are planned and non-urgent, like cosmetic surgery. Hemorrhaging is life-threatening, requiring immediate intervention, not a scheduled event, making elective an incorrect classification.

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A nurse is caring for a client with left arm weakness. Which nursing action is most important to prevent contractures?

Nursing Test Bank

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Correct Answer is C

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