The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.

Continue PROM if joint's muscle spasms to relax muscle.

Slowly stretch the joint's muscles if pain is present.

Move the joint slowly until resistance is felt.

Instruct the client to relax during the exercises.

Support the extremity of the joint being exercised.

Answer and Explanation

Correct Answer : C,D,E

A. Continue PROM if joint's muscle spasms to relax muscle: Continuing to move a joint during muscle spasms can worsen injury or cause pain. PROM should be stopped if spasms occur and reassessed to prevent harm.

B. Slowly stretch the joint's muscles if pain is present: Stretching a joint when pain is present can cause tissue damage or exacerbate injury. Pain indicates that the joint has reached its limit, so exercises should be within a pain-free range.

C. Move the joint slowly until resistance is felt: Moving the joint slowly until resistance allows for safe assessment of mobility and flexibility without overstretching or causing injury. Resistance provides a natural limit to the joint’s passive range of motion.

D. Instruct the client to relax during the exercises: Relaxation reduces muscle tension, allowing for safer and more effective passive movements. Client cooperation helps prevent muscle guarding and ensures proper joint mobilization.

E. Support the extremity of the joint being exercised: Supporting the extremity prevents undue stress on muscles and joints, reduces the risk of injury, and allows controlled movement during PROM exercises. Proper support is essential for safety.

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Correct Answer is D

Explanation

A. Noncompliance with treatment regimen: While noncompliance can affect recovery, it is secondary to the immediate physiological risks posed by malnutrition. Addressing noncompliance becomes relevant after stabilizing the client’s health.

B. Disturbed Body Image: Distorted body image is a core psychological issue in anorexia nervosa, but it does not pose an immediate threat to the client’s life. Interventions targeting body image are important but not the first priority.

C. Interrupted Family Processes: Family dynamics may influence the client’s condition and recovery, yet they are not life-threatening. Family interventions are supportive and adjunctive to stabilizing the client’s nutritional status.

D. Imbalanced Nutrition: less than body requirements: Malnutrition directly threatens the adolescent’s physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Correcting nutritional deficits and preventing complications such as electrolyte imbalance or organ failure is the highest priority in care planning.

A. Urge the client to have regular STI screening every two years. B. Answer questions directly and correct any misinformation. C. Clarify that all STIs are transmitted through sexual intercourse. D. Provide counseling that most contraceptives protect against infection.

Correct Answer is B

Explanation

A. Urge the client to have regular STI screening every two years: Screening every two years is insufficient for individuals with recurrent STIs. More frequent testing is recommended to prevent reinfection and detect new infections early.

B. Answer questions directly and correct any misinformation: Providing accurate, evidence-based information helps the client understand STI transmission, prevention, and treatment. Direct responses foster trust, support informed decision-making, and address misconceptions effectively.

C. Clarify that all STIs are transmitted through sexual intercourse: Not all STIs are transmitted solely through intercourse; some, like herpes or HPV, can be transmitted via skin-to-skin contact. This statement could be misleading and does not fully educate the client.

D. Provide counseling that most contraceptives protect against infection: Most contraceptives, such as oral contraceptives or IUDs, do not protect against STIs. Only barrier methods, like condoms, reduce the risk of STI transmission.

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The nurse is performing a musculoskeletal assessment with a client. Which action(s) should the nurse implement when performing passive range of motion (PROM) exercises with a client? Select all that apply.

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Explanation

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