A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?
Each movement is performed until the patient reports pain.
Each movement is moved just to the point of resistance by the nurse.
Each movement is repeated 5 times by the patient.
Each movement is completed quickly and smoothly by the nurse.
The Correct Answer is B
A. Performing movements until the patient reports pain is inappropriate in passive range of motion, as the goal is to maintain joint function without causing discomfort.
B. Moving each joint to the point of resistance helps to maintain flexibility and prevent stiffness without causing harm, making this the appropriate technique.
C. Repeating movements five times by the patient is not applicable for passive range of motion, which is performed by the nurse on a patient who cannot do it themselves.
D. While smooth movements are essential, they should not be done quickly; the focus should be on the patient's comfort and safety, avoiding rapid or jerky motions.
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Correct Answer is C
Explanation
A. Cultural values regarding cleanliness vary, so it is inaccurate to assume uniform standards.
B. Judging the patient as placing "little importance" on hygiene due to appearance can lead to biases and does not consider the patient’s routine.
C. Diabetes may necessitate changes in hygiene practices, especially regarding foot care, to prevent complications. Education on optimal hygiene practices is essential for health management in diabetic patients.
D. While personal preferences influence hygiene, they can be adapted with appropriate education and guidance when necessary for health reasons.
Correct Answer is D
Explanation
A. Vision is not commonly affected by vancomycin, so it is not a priority to assess.
B. Heart tones are not directly impacted by vancomycin and do not require immediate monitoring unless there are specific cardiovascular concerns.
C. Bowel sounds are not directly influenced by vancomycin and do not need to be prioritized in this case.
D. Vancomycin is known to be ototoxic, especially in high doses or with prolonged use, so monitoring for signs of hearing loss or tinnitus is essential to prevent potential irreversible damage.