Patient Data
|
Joint |
Type of Range of Motion |
|
Shoulder - unable to move the arm away from the body
|
Shoulder - Flexion Shoulder - Adduction Shoulder - Extension Shoulder - Abduction |
|
Wrist - able to bend wrist back toward forearm
|
Wrist - Extension Wrist - Adduction Wrist - Abduction Wrist - Flexion |
|
Elbow - only able to straighten joint20 degrees
|
Elbow - Flexion Elbow - Extension Elbow - Adduction Elbow - Abduction |
Shoulder - Adduction
Shoulder - Abduction
Wrist - Extension
Wrist - Abduction
Elbow - Flexion
Elbow - Extension
The Correct Answer is ["B","C","F"]
Rationale for correct choices:
• Shoulder: Abduction is the movement of the arm away from the midline of the body. The client’s inability to move the shoulder away from the body indicates a limitation in abduction. Assessing abduction is important after a stroke because hemiparesis or muscle weakness can limit the range of motion in this direction. This finding helps the nurse plan interventions such as passive range-of-motion exercises to maintain joint mobility.
• Wrist: Extension at the wrist refers to bending the wrist backward, toward the dorsal side of the forearm. The client’s ability to bend the wrist backward demonstrates preserved extension. Evaluating wrist extension is important for functional hand movements and self-care activities. Preserving wrist extension can help maintain grip and overall function during rehabilitation.
• Elbow: The elbow joint primarily performs flexion (bending) and extension (straightening). If the nurse is assessing the ability to straighten the arm, they are assessing Extension. A finding of "only 20 degrees" indicates a significant contracture or loss of ROM.
Rationale for incorrect choices
• Adduction : Adduction refers to movement toward the body’s midline. The client’s limitation is moving the shoulder away from the body, which is opposite of adduction. Similarly, the elbow and wrist assessments do not involve movement toward the midline. Selecting adduction would not correctly describe the observed range-of-motion limitations.
• Extension: Extension is the movement that increases the angle between two bones. The shoulder cannot extend away from the body in this scenario, and the elbow is only partially straightened, so extension is limited. The shoulder’s primary limitation is abduction.
• Abduction: Abduction is movement away from the midline, relevant primarily to shoulder and fingers. The wrist is assessed for flexion and extension, and the elbow is assessed for flexion/extension, not abduction. Selecting abduction for these joints would not match the observed movements and limits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Give the client an object to hold: Providing an object is not necessary for assessing basic muscle strength and may interfere with accurately evaluating the client’s ability to perform isolated movements. It is more relevant in functional or fine motor assessments rather than strength testing.
B. Palpate the client's muscle tone: Before testing active movements like flexion, the nurse should assess muscle tone through palpation. This allows the PN to detect hypotonia, hypertonia, or spasticity, which can affect strength testing and provide baseline information about neuromuscular function.
C. Instruct the client to close their eyes: Closing the eyes may be useful for assessing proprioception or coordination but is not essential for evaluating basic upper extremity muscle strength. Vision does not significantly impact isolated strength assessment.
D. Apply resistance to the client's arms: Resistance testing occurs after observing the client’s active movement. Applying resistance prematurely could cause discomfort or injury if the nurse has not first assessed baseline tone and voluntary control of the muscles.
Correct Answer is C
Explanation
Rationale:
A. Assess orientation to person, place, and time: Assessing orientation evaluates cognitive status and level of consciousness but does not directly address the client’s vestibular function or the sensation of vertigo. Cognitive intactness may coexist with vertigo and is not specific for this symptom.
B. Listen for changes in speech patterns: Changes in speech can indicate neurological deficits such as dysarthria or stroke. While relevant for a general neurological assessment, speech patterns do not provide information about the inner ear or vestibular disturbances that cause vertigo.
C. Inquire about sensations of spinning around: Vertigo is characterized by the subjective perception of movement or spinning, either of the environment or the person, often related to vestibular dysfunction. Asking the client to describe these sensations directly assesses the hallmark symptom of vertigo and helps differentiate it from other causes of dizziness or imbalance.
D. Measure blood pressure while standing: Orthostatic hypotension can cause lightheadedness or dizziness but is distinct from true vertigo. While assessing for positional changes in blood pressure is important for syncope evaluation, it does not directly assess the spinning or rotational sensations characteristic of vertigo.
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