Mrs. Tano, 60 years old, was admitted because of cerebrovascular accident (CVA) resulting to paralysis of the left side of the body.
1. you planned to start passive range of motion exercise today. Which of the following should you avoid in the passive range of motion exercises?
A. The extremity should be supported particularly the bones below and above the exercising joint
B. During the passive exercises, the client should be lying in the supine position
C. Each joint should be moved slowly through its full range
D. If a joint appears to be stiff, the exercise should be continued slightly beyond the point of the pain
2. One day, while taking the usual rounds of your clients in the ward, you realize that Mrs. Tano has been lying in the same position for more than two hours. You are very much concerned because:
A. Mrs. Tano is vulnerable to the development of presure sores during this period
B. The husband has been complaining about her wife's care and you are worried that the husband might report you to the supervisor
C. Mrs. Tano is vulnerable to the development of contractures in this period
D. You have repeatedly instructed the attempt to turn Mrs. Tano every two hours
3. You went to see Mrs. Tano to assess the integrity of her skin because of your concern that she has not been turned. When you check her bony prominence on one side, you noted that there is a beginning pressure sore formation because:
A. You know that the attendant did not turn Mrs. Tano to the sides
B. Her skin is red to purple gray and hot to touch
C. The skin is pink and warm to touch
D. You know that Mrs. Tano has not been eating well and she is at risk for pressure
4. You have known that the most important reason for bedsores as a threat to Mrs. Tano's skin integrity is:
A. Moisture from perspiration can produce laceration of the skin
B. Excessive pressure collapses blood vessels and impedes blood flow eventually causing tissue damage
C. Invasion of microorganism creates infection of the skin which has been subjected to continuous pressure over time
D. Friction allows pulling of tissue, thus stretching and injuring tissue and blood vessels
5. Your priority intervention with Mrs. Tano when you discover she is developing pressure sores would be to:
A. Rub affected area vigorously to stimulate circulation
B. Relieve pressure to prevent interference with blood flow
C. Cleanse the area well with alcohol to prevent infection
D. Increase fluids to prevent electrolyte imbalance
