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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A) Four wheel walker: While a four-wheel walker provides excellent support and stability for clients with significant mobility limitations, it is not always the best choice for someone who occasionally loses balance. It can be bulky and difficult to maneuver in tight spaces, and it may not provide as much support for clients who need only occasional assistance with balance. A gait belt allows for more hands-on assistance when needed.

B) Gait belt: A gait belt is the most appropriate device to use when assisting a client who occasionally loses balance. It allows the nurse to provide hands-on support and maintain the client’s safety during ambulation. The gait belt provides a secure hold, enabling the nurse to assist the client in regaining balance quickly, preventing falls if the client starts to lose their stability.

C) Jacket harness: A jacket harness is typically used in more severe cases of balance loss or in situations where the client has significant mobility impairments. While it provides more overall support, it may not be necessary for a client who only occasionally loses balance. It can also be more cumbersome than a gait belt for helping with short, occasional ambulation.

D) Cane: A cane is helpful for clients who need mild to moderate support while walking, but it might not offer enough stability for a client who occasionally loses balance. A cane may provide support in some cases, but using a gait belt would be more effective for safely supporting and guiding the client during ambulation.

A. Droplet B. Contact C. Airborne D. Protective environment

Correct Answer is C

Explanation

A) Droplet: Droplet precautions are used for infections that spread through respiratory droplets when an infected person coughs, sneezes, or talks. While measles is transmitted through respiratory droplets, the virus is highly contagious and requires airborne precautions, not just droplet precautions.

B) Contact: Contact precautions are used for infections spread through direct contact with the patient or their environment, such as gastrointestinal or skin infections. Measles is primarily spread through the air and is not classified as a contact transmission infection.

C) Airborne: Measles is an airborne illness, which means that it can be transmitted through small respiratory droplets that remain suspended in the air for long periods of time. Airborne precautions are necessary to protect healthcare workers and other patients from exposure. These precautions include placing the child in a negative pressure room and requiring healthcare workers to wear N95 respirators.

D) Protective environment: Protective environment precautions are used for patients with severely weakened immune systems, such as those undergoing chemotherapy or organ transplantation. These precautions are designed to protect the patient from infections, not to prevent the spread of contagious illnesses like measles.

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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?

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