Answer to Question 1
Correct Answer: 3
Rationale 1: Stopping the treatment is not justified until an assessment occurs.
Rationale 2: Stopping the exercises is not justified until an assessment occurs.
Rationale 3: Range-of-motion exercising should never cause discomfort. In this case, the best action is to reduce the movement of the joint just until the point of slight resistance is felt and evaluate the pain response at that level. If there is no pain, the exercise can be continued.
Rationale 4: Continuing at the same level of intensity may cause damage to the joint as well as cause the client pain.
Answer to Question 2
Correct Answer: 2, 4, 5
Rationale 1: The can should be held on the stronger side of the body to provide maximum support and appropriate body alignment while walking.
Rationale 2: The cane should be moved forward while the body weight is borne by both legs.
Rationale 3: The length should permit the elbow to be slightly flexed.
Rationale 4: The weaker leg is moved forward while the weight is borne by the cane and stronger leg.
Rationale 5: The stronger leg is moved forward while the weight is borne by the cane and weak leg.
The nurse needs to note the source of the patient health history
The nurse is using Standard Precautions to draw blood.
The surgical nurse assists the client into the correct position
The nurse cares for the postop client in the postanesthesia care unit (PACU).
Goniometer measure of joint range of motion
Retrograde Motion of Mars