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Nur 236 chapters 31 and 32 muscle skeletal questions fully solved
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Nur 236 chapters 31 and 32 muscle skeletal questions fully solved
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Nur 236 chapters 31 and 32 muscleskeletal
The nurse is discussing actions that can be taken to best prevent osteoporosis with a patient. Which
information should the nurse include? - correct answer ✔✔Exercise throughout life.
A lifetime of even mild daily exercise will delay or prevent osteoporosis.
What does goniometry measure? - correct answer ✔✔Range-of-motion (ROM)
Goniometry measures joint mobility, described as the number of degrees that the joint can move from
the 0-degree mark.
Positioning and range-of-motion (ROM) exercises most help the immobilized patient to prevent which
complication? - correct answer ✔✔Contractures
Although positioning may help decrease pain and increase circulation, anatomical alignment and ROM
exercises are most helpful in preventing contractures in the immobilized patient. Pressure ulcers are
prevented by frequent position changes.
The nurse adds interventions for range-of-motion (ROM) and isometric exercises for the new patient
with a stroke. The nurse's reasoning stems from her awareness that contracture formation may begin
with how many days of immobilization? - correct answer ✔✔3 days
Contracture-related muscle changes occur as early as 3 days of immobilization.
If muscles are not regularly stretched and contracted, how will the muscles be effected? - correct answer
✔✔Muscles will become shorter and less elastic
,The formation of contractures (shortening of skeletal muscle tissue causing deformity), loss of muscle
tone, and fixation of joints can be prevented in most cases by consistent nursing intervention. The major
components of the intervention are gradual mobilization, an exercise program, proper positioning, and
instruction of the patient and family. Within a matter of a few days, the structures of immobilized
muscles and joints begin to undergo changes. If no effort is made to prevent these changes, the patient
will become permanently disabled.
The nurse uses a visual aid to show the pathologic muscle tone changes that result in foot drop. Which
changes should the nurse include? - correct answer ✔✔The stretching of flexor muscles
The most frequent contractures occurring in patients immobilized for long periods are "foot drop," knee
and hip flexion contractures, "wrist drop," and contractures of the fingers and arms. Calf muscles
contract and flexor muscles are stretched, allowing the unbraced foot to drop toward the surface of the
bed.
How often should range-of-motion (ROM) exercises be performed? - correct answer ✔✔Three to four
times a day
ROM exercises, both passive and active, are planned and carried out as soon as feasible after
immobilization occurs as a result of disease, injury, or surgery. The exercises are done to maintain
functional connective tissue within the joint and thereby ensure that every joint retains its function and
mobility. ROM exercises should be done three to four times a day.
The physician has prescribed isometric exercises for a patient. For which patient should the nurse
question this order? - correct answer ✔✔A patient experiencing an acute exacerbation of congestive
heart failure
Isometric exercises are based on the energy of opposing muscles working against each other. Isometric
exercise may be contraindicated in patients with hypertension, increased intracranial pressure, or
congestive heart failure, as there is a significant increase in blood pressure and heart rate during
isometric exercise
, When the patient returns to the unit from having had an arthrogram, which intervention should the
nurse perform first? - correct answer ✔✔Apply ice packs to the knee
Ice packs applied to the knee will reduce swelling. The patient will ambulate at some point but not
before the application of ice. There is not going to be a significant loss of mobility for the patient, so
ROM exercises will not likely be included in the plan of care. There is no indication that an elastic
bandage is needed.
The nurse encourages the patient to use the four-point crutch gait technique. Which statement indicates
that the patient accurately understands the nurse's teaching? - correct answer ✔✔This way of walking is
the most stable gait."
The four-point crutch gait is the most stable, requires that there may be partial weight bearing on both
legs, and does not mimic normal walking pattern.
The nurse is assessing the patient's cane for appropriate length. Which observation affirms that an
appropriate cane has been selected? - correct answer ✔✔The handgrip is at hip level.
The handgrip should be at hip level to allow for proper flexion of the arm to bear weight. The cane tip
should be placed 6 inches from the good foot. The elbow angle should be 30 degrees
The nurse is instructing the patient on quadriceps and gluteal muscle exercises. Which instructions
should the nurse include? - correct answer ✔✔In a supine position, straighten the leg and tense leg
muscles while raising heel.
The quad setting exercise is to straighten the leg and tense the leg muscles while raising the heel
What is the name for the anatomical structure that joins the bones of a joint together? - correct answer
✔✔A ligament
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