A nurse is teaching a client about the benefits of passive range of motion (ROM) exercises. Which of the following descriptions by the client indicates a correct understanding?
Prevents bone degeneration
Prevents muscle atrophy
Increases muscle mass
Maintains joint mobility
The Correct Answer is D
Reasoning:
Passive range of motion involves the external manipulation of joints to maintain existing flexibility and prevent structural complications. It is indicated for patients who are unable to independently move their extremities due to neurological deficit, sedation, or physical restriction to preserve synovial fluid distribution and prevent permanent joint contractures.
A. Passive range of motion does not provide the necessary mechanical loading or weight-bearing stress required to stimulate osteoblastic activity. Bone density is maintained primarily through active, weight-bearing exercises that stress the skeletal system. Without such stress, bone resorption outpaces formation regardless of passive joint movement.
B. Muscle atrophy is a physiological reduction in muscle fiber diameter resulting from a lack of active contraction. Since passive ROM does not involve the client’s voluntary motor unit recruitment or muscular work, it cannot prevent the metabolic and structural breakdown of muscle tissue associated with prolonged immobility.
C. Hypertrophy or an increase in muscle mass requires resistance training and active metabolic demand to stimulate protein synthesis within myofibrils. Passive ROM involves no active engagement of the client's musculoskeletal system; therefore, it is physiologically impossible for this intervention to result in increased muscle mass.
D. The primary therapeutic goal of passive ROM is to maintain the current flexibility of the joint and surrounding connective tissues. By moving the joint through its full available arc, the nurse helps prevent the shortening of ligaments and tendons, ensuring the joint remains functional for future use.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reasoning:
The standard physical assessment sequence is designed to ensure data accuracy and minimize clinician-induced artifacts. For most body systems, the order moves from the least invasive to the most invasive technique. This prevents the alteration of physical findings, such as bowel sounds or tenderness, before they can be properly assessed.
A. Starting with auscultation is generally incorrect for a standard head-to-toe assessment. Techniques like palpation and percussion should always be preceded by inspection to gather visual data. The only exception to the standard order is the abdominal assessment, where auscultation follows inspection to avoid altering bowel motility.
B. This sequence is incorrect because palpation and percussion are reversed. Palpation (using touch to feel for surface characteristics) usually precedes percussion (tapping to assess underlying density) in a standard systemic review. Performing percussion before palpation might unnecessarily agitate the tissue or cause discomfort that interferes with palpation.
C. The sequence of inspection, palpation, percussion, and auscultation is the standard for assessing most body systems (excluding the abdomen). Inspection provides visual cues, palpation assesses texture and temperature, percussion determines the density of underlying structures, and auscultation captures internal sounds produced by organs like the heart and lungs.
D. Palpation should never be the first step in an assessment. Starting with palpation can mask subtle visual findings and may cause the patient to guard or tense their muscles, making the rest of the examination difficult. Inspection must always be the first step to establish a baseline.
Correct Answer is C
Explanation
Reasoning:
The apical pulse, or the point of maximal impulse (PMI), corresponds to the location where the left ventricular apex is closest to the thoracic wall. Precise anatomical localization at the left fifth intercostal space is essential for the accurate auscultation of heart rate and rhythm, particularly in patients with hemodynamic instability or dysrhythmias where peripheral pulses may be inaccurate.
A. The right second intercostal space at the sternal border is the anatomical landmark for auscultating the aortic valve area. While important for a cardiac assessment, this location does not provide an accurate measurement of the apical pulse, which is situated much lower and more lateral in the chest cavity.
B. The left shoulder region near the acromion process is not a cardiac landmark. Placing a stethoscope here would result in the auscultation of skeletal muscle or referred sounds but would not allow the nurse to hear the cardiac cycle or the closing of the mitral and tricuspid valves.
C. The left fifth intercostal space at the midclavicular line is the correct landmark for the apical pulse. This location provides the clearest sound of the mitral valve and the tricuspid valve closure. It is the standard site for counting the heart rate for a full minute before administering medications like digoxin.
D. The mid-sternum at the angle of Louis is used as a reference point for counting intercostal spaces and locating the second rib. While it is a critical landmark for orientation, it is not the location where the heart's apex is found or where a pulse should be counted.
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