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A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

Determining the client's mobility

Explaining the roles of the RN, licensed practical nurse, and assistive personnel

Introducing health care team members to the client

Understanding the client's routine for his own care at home

Answer and Explanation

The Correct Answer is D

A. Determining the client's mobility

Important for safety and fall prevention, but not the first priority during care planning.

B. Explaining the roles of the RN, licensed practical nurse, and assistive personnel

This is part of orientation and education but does not help in personalized care planning.

C. Introducing health care team members to the client

While courteous and important for building rapport, it’s not the first step in individualized care planning.

D. Understanding the client's routine for his own care at home

This helps in personalizing the care plan to maintain the client’s independence and preferences, especially for older adults in long-term care.

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Correct Answer is D

Explanation

A. Turn their foot and leg away from their other leg

This movement is called external rotation, not hyperextension.

B. Move their leg forward and up

This action is flexion of the hip.

C. Move their leg medially toward their other leg

This describes adduction, moving the limb toward the body's midline.

D. Move their leg behind their body

Hyperextension of the hip involves moving the leg backward beyond the normal range of extension.

A. Hyperextension B. Lateral flexion C. Rotation D. Flexion

Correct Answer is D

Explanation

A. Hyperextension

Hyperextension refers to bending backward beyond the normal range.

B. Lateral flexion

Lateral flexion involves bending the neck to the side, ear toward shoulder.

C. Rotation

Rotation refers to turning the head side-to-side (e.g., shaking head “no”).

D. Flexion

Touching the chin to the chest is flexion of the neck-bending forward.

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A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse stands facing a client to demonstrate active range-of-motion exercises. Which of the following actions should the nurse take to demonstrate hyperextension of the hip?

Correct Answer is D

Explanation

A nurse is assisting a client with range-of-motion exercises of the neck. Which of the following terms should the nurse use when documenting the client touching her chin to her chest?

Correct Answer is D

Explanation

A nurse is assisting a client with range-of-motion exercises of the shoulders. Which of the following terms should the nurse use when documenting the client raising his arm from his side to above his head?

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