Author Question: The nurse is assessing an older adult client during a routine health maintenance visit. To assess ... (Read 115 times)

evelyn o bentley · **on:** Jun 25, 2018

The nurse is assessing an older adult client during a routine health maintenance visit. To assess the client's range of motion of the knees, which action by the nurse is appropriate?

A) Seat the client and extend the knee until the client alerts the nurse of severe pain.
B) Seat the client and instruct to alert the nurse of any pain.
C) Place the client prone and gently lift the entire leg.
D) Have the client stand and extend the knee as far as it will go.

Question 2

A young adult female student is brought into the emergency department by her roommate. The roommate says, She came home from a party at her boyfriend's house and said that he raped her. Which techniques are appropriate when assessing this clie

Select all that apply.
A) Inquire how many sexual partners she has had.
B) Offer to use a rape evidence collection kit.
C) Ask her if she has ever had a sexually transmitted infection.
D) Assess for the presence of an intact hymen.
E) Ask her if she led her boyfriend on in any way.

Dominic · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: B

To assess the range of motion of the knees the client should be placed in a sitting position. The nurse will instruct the client to alert the nurse at the first sign of discomfort when checking range of motion of the knee. Seating the client is appropriate, but the knee is not forced beyond the pain limit. Placing the client prone and lifting the entire leg checks the range of the hips. The client will not be asked to stand when assessing range of motion of the knees.

Answer to Question 2

Answer: B, D

It is inappropriate to ask her how many sexual partners she has had, if she has ever had a sexually transmitted infection, or if she led her boyfriend on. You should offer to use a rape evidence collection kit. It is also inappropriate to assess for the presence of an intact hymen.