A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?

Each movement is performed until the patient reports pain.

Each movement is moved just to the point of resistance by the nurse.

Each movement is repeated 5 times by the patient.

Each movement is completed quickly and smoothly by the nurse.

Answer and Explanation

The Correct Answer is B

A. Performing movements until the patient reports pain is inappropriate in passive range of motion, as the goal is to maintain joint function without causing discomfort.
B. Moving each joint to the point of resistance helps to maintain flexibility and prevent stiffness without causing harm, making this the appropriate technique.
C. Repeating movements five times by the patient is not applicable for passive range of motion, which is performed by the nurse on a patient who cannot do it themselves.
D. While smooth movements are essential, they should not be done quickly; the focus should be on the patient's comfort and safety, avoiding rapid or jerky motions.

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Correct Answer is B

Explanation

A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.

A. Risk for infection related to chest x-ray procedure B. Impaired gas exchange related to alveolar-capillary membrane changes C. Risk for deficient fluid volume related to dehydration D. Ineffective breathing pattern related to pneumonia

Correct Answer is B

Explanation

A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.

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A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?

Nursing Test Bank

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