A patient is admitted with a stroke. The outcome of this disorder is uncertain, but the patient is unable to move the right arm and leg. The nurse starts passive range-of-motion (ROM) exercises. Which finding Indicates successful goal achievement?
Contractures developed.
Muscle strength improved.
Heart rate decreased
joint mobility maintained
The Correct Answer is D
A) Contractures developed: The development of contractures indicates a lack of proper joint movement or stretching, which can occur if passive range-of-motion (ROM) exercises are not performed appropriately. Contractures are an undesirable outcome that occurs when joints or muscles become stiff and shortened, which hinders mobility. The goal of passive ROM exercises is to prevent this, so the development of contractures would indicate failure to meet the goal.
B) Muscle strength improved: Passive range-of-motion exercises do not directly improve muscle strength. They are designed to maintain joint flexibility and prevent complications like contractures in individuals who are unable to move their limbs actively. Strengthening muscles typically requires active participation, which would be more effectively addressed with active ROM exercises or resistance training as appropriate.
C) Heart rate decreased: While physical activity can influence heart rate, passive ROM exercises primarily aim to maintain joint mobility and prevent complications like contractures. A decrease in heart rate would not be an indicator of successful passive ROM exercises. The focus here is on joint flexibility and prevention of stiffness, rather than cardiovascular effects.
D) Joint mobility maintained: Successful goal achievement in passive range-of-motion exercises is indicated by the maintenance of joint mobility. These exercises help prevent the stiffening of joints, preserve range of motion, and promote circulation. If the patient’s joint mobility is maintained, it shows that the passive ROM exercises are effectively preventing contractures and promoting the best possible outcome for the patient’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Tanning beds are much safer than lying in the sun: This statement is inaccurate. Tanning beds can actually be more harmful than sun exposure, as they expose the skin to concentrated ultraviolet (UV) radiation, which increases the risk of skin cancer, premature aging, and other skin damage. Health promotion teaching should focus on the dangers of tanning and emphasize safe sun practices, such as using sunscreen and avoiding tanning beds.
B) "Share piercing needles only with close friends you trust": This statement is dangerous and misleading. Sharing needles for piercings or tattoos, regardless of trust, can transmit bloodborne infections such as HIV, hepatitis B, and hepatitis C. The nurse should emphasize the importance of using sterilized, single-use needles and ensuring proper hygiene to prevent infections.
C) Your need for sleep will increase during periods of growth: This statement is accurate. Adolescents experience significant physical and cognitive growth, which increases their need for sleep. The nurse should encourage adolescents to prioritize adequate sleep, as it is essential for physical development, emotional well-being, and overall health.
D) "Limit your caloric intake to avoid becoming overweight": While maintaining a balanced diet is important, the focus should not be solely on limiting caloric intake. Adolescents are in a period of rapid growth and development, and their nutritional needs are higher. Health promotion should emphasize eating a balanced diet with appropriate portions of nutrients rather than focusing on restricting calories.
Correct Answer is C
Explanation
A) A nurse who works for an insurance company and collects urine samples from clients who have HIV: While this nurse may interact with clients who have HIV, collecting urine samples does not typically pose a significant risk for HIV transmission. HIV is not transmitted through urine, and the nurse would not be in direct contact with blood or bodily fluids that present a risk.
B) A personal trainer who works with a client who has HIV: A personal trainer is at low risk for contracting HIV while working with a client who has the virus, provided there is no direct exposure to blood or open wounds. HIV is transmitted through specific bodily fluids such as blood, semen, vaginal fluids, and breast milk, and not through casual contact or physical activity like exercise.
C) A phlebotomist who collects blood from clients who have HIV: A phlebotomist is at the greatest risk of contracting HIV because they handle blood directly. If proper precautions, such as gloves and safe needle handling, are not followed, there is an increased risk of exposure to HIV-infected blood. Occupational exposure to blood is one of the most significant routes of HIV transmission in healthcare settings.
D) An occupational therapist who works with a client who has HIV: An occupational therapist working with a client who has HIV is at a low risk of contracting HIV, provided the therapist does not come into direct contact with blood or other potentially infectious bodily fluids. Occupational therapy generally involves helping clients with physical or cognitive tasks and does not typically present a risk for HIV transmission unless there is a breach in infection control practices.
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