Vernon Russell Assessment VSIM

The nurse is completing passive range of motion on Mr.Russell. What movements would the nurse expect to complete at the elbow joint?

Flexion, extenison, supination, pronation

The nurse is educating Mr. Russell on how to prevent falls. Which statement, if made by the patient, indicates that he understood the teaching?

I should press my call light when i want to get out of bed

The nurse is reviewing MR.Russell's medications. Which medication(s) would place Mr.Russell at a higher risk for falls?(select all that apply)

Losartan, metformin, Chlorthalidone

The nurse is assessing the muscle strength in Mr.Russell's left hand and notes active motion against some resistance. How would the nurse document this finding?

4

The nurse is assessing flexion in Mr.Russell's hip. What instructions would the nurse give to Mr.Russell to complete this assessment?

Bend you knee to your chest, and then pull it against you abdomen

The nurse is using the Morse Fall Scale to determine Mr.Russell's fall risk. What variable(s) will the nurse assess by using this tool?(Select all that apply)

secondary diagnosis, presence of IV, history of falls

Mr. Russell asks the nurse, "What is the purpose of these passive rang of motion (ROM) exercises? I can move my own arms and legs." What is the correct response by the nurse?

Passive range of motion exercises will help you to maintain mobility in your joints

THe nurse is educating Mr.Russell on the effects of prolonged immobility. What physiologic change(S) would the nurse describe to Mr.Russell? (select all that apply)

decreased muscle mass, increased muscle catabolism, bone demineralization, decreased muscle protein synthesis

The nurse is caring for Mr.Russell, who is recovering from a stroke and has mid left sided hemiplegia. What would the nurse include in the plan of care?(Select all that apply)

encourage the pt to set realistic short term goals, Perform passive range of motion exercises

The nurse is implementing a progressive mobility regimen on a patient who has been prolonged bed rest. list the steps of the procedure in the order they should be performed

raise the head of bed to 30 degrees raise the head of bed to 45 degrees position bed at 45 degrees, legs dependent position bed at 65 degrees, legs dependent position bed at 65 degrees, feet on floor