A nurse is performing passive range of motion exercises on a client who had a lacunar cerebrovascular accident nine days ago. While moving the left arm, the affected extremity, the nurse notes muscular spasticity. What is the nurse's next action?

  1. Notify the physician
  2. Continue with the range of motion exercises
  3. Apply gentle pressure on the spastic part
  4. Administer PRN pain medication, if there is any
Explanation

Answer: C - In case of muscle spasticity, the nurse's next action is to temporarily discontinue the exercise and continue the application of gentle pressure on the spastic part until the muscle relaxes. Range of motion exercises should be discontinued if the client reports discomfort, pain, stiffness or rigidity, and other unexpected symptoms. If these symptoms occur the physician should be notified. Pain medications are ideally given prior to exercises to gain the client's cooperation.

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