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A nurse is providing passive range of motion (ROM) for a patient with impaired mobility. Which technique will the nurse use for each movement?

A.

Each movement is performed until the patient reports pain.

B.

Each movement is moved just to the point of resistance by the nurse.

C.

Each movement is repeated 5 times by the patient.

D.

Each movement is completed quickly and smoothly by the nurse.

Answer and Explanation

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 A

Explanation

A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.

B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.

C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.

D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.

Correct Answer is A

Explanation

A. This observation indicates proper body alignment as the arms hanging comfortably at the sides suggest relaxation and good posture.

B. The edge of the seat should not be in contact with the popliteal space; there should be a small gap to prevent pressure and improve circulation.

C. While the feet should be supported on the floor, they should be flat rather than flexed at the ankles for optimal alignment.

D. The body weight should be distributed between the buttocks and thighs, not just on the buttocks, to promote comfort and good posture.

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