A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

Move body parts rapidly through the movements.

Support extremities above and below joints.

Continue moving body parts if muscle spasticity occurs.

Stretch the body part just beyond the existing range of motion.

Answer and Explanation

The Correct Answer is B

A. Move body parts rapidly through the movements. Passive range of motion (ROM) should be performed slowly and gently to prevent injury or pain.

B. Support extremities above and below joints. Supporting both above and below the joint helps prevent excessive strain and allows for controlled movement.

C. Continue moving body parts if muscle spasticity occurs. If muscle spasticity occurs, the nurse should stop and reassess before continuing, to avoid injuring the client.

D. Stretch the body part just beyond the existing range of motion. The nurse should never push beyond the client’s normal range, as this can cause pain or injury.

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Correct Answer is B

Explanation

A. Maintenance of good posture. While good posture can promote better bowel motility, it is not a primary intervention for constipation.

B. Increased fiber and fluid in the diet. Increasing dietary fiber (whole grains, fruits, vegetables) and fluid intake softens stool and promotes regular bowel movements, making this the best recommendation.

C. Regular use of a laxative. Frequent use of stimulant laxatives can lead to dependence, making it an inappropriate first-line intervention.

D. Regular use of glycerin suppositories. Glycerin suppositories are used for occasional relief of constipation but are not recommended for routine use as they do not address the underlying cause.

A. 4+ B. 3+ C. 2+ D. 1+

Correct Answer is B

Explanation

A. 4+: 4+ pitting edema corresponds to an indentation of 8 mm or more, which is more severe than the 6 mm described in the question.

B. 3+: 3+ pitting edema is characterized by an indentation of 6 mm and indicates moderately severe fluid retention.

C. 2+: 2+ pitting edema corresponds to an indentation of 4 mm, which is less than the 6 mm described.

D. 1+: 1+ pitting edema corresponds to an indentation of 2 mm, which is mild and does not match the severity in the scenario.

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A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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