PLEASE HELP me with this SATA Q

Nursing Students NCLEX

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A nurse is providing educationto the family of a client scheduled for discharge. The client, whohas severe cognitive impairments, is a recent quadriplegic. Thefamily has questions about the need to perform range-of-motion ofexercises with the client. What information should the teachingsession include? Select all that apply.

1."Use sheepskin pads in the bed andwheelchair."

2."The skin and underlying structures will beginto become anoxic after 2 hours of unrelieved pressure."

3."Friction and shear increase a paralyzedclient's risk of pressure ulcers."

4."Positioning the client at 90 degrees from thehead of the bed is most therapeutic."

5."You need to perform range-of-motion exercisesonly when the client asks you to do so."

ANSWER=1 & 3

When I first looked at this question I became very focused on, "The family has questions about the need to perform range-of-motion of exercises with the client."

Looking at the options, I noticed Option(s) 4 & 5 were the only 2 options which had anything to do with ROM and Positioning (keeping in mind positioning the pt properly to preform ROM exercises correctly)

BUT... I knew that the info provided in 4 & 5 was inaccurate. RATIONALE: Thirty degrees from the head of the bed is the most therapeutic angle of positioning. & The family should perform range-of-motion exercises every time they reposition the client (Also, since the pthas "severe cognitive impairments" the pt may not ask to be repositioned)

So I was able to r/ooptions 4 & 5. BUT then was left with 1-3 (which I felt do not answer the family's questions about the NEED to preform ROM exercises with the pt).

At this point I became irritated/frustrated... I knew Options 1 & 3 were accurate statements... BUT felt they weren't addressing the family's concerns.

Thinking to myself now....What if the info provided in Options 4&5 were accurate and instead I was presented with the following:

A nurse is providing education to the family of a client scheduled for discharge. The client, who has severe cognitive impairments, is a recent quadriplegic. The family has questions about the need to perform range-of-motion of exercises with the client. What information should the teaching session include? Select all that apply.

1."Use sheepskin pads in the bed and wheelchair."

2."The skin and underlying structures will begin to become anoxic after 2 hours of unrelieved pressure."

3."Friction and shear increase a paralyzed client's risk of pressure ulcers."

4."Positioning the client at 30 degrees from the head of the bed is most therapeutic."

5."You need to perform range-of-motion exercises every time they reposition the client."

In this scenario, I would have selected ONLY Options 4 & 5 as they directly answered questions about the NEED to preform ROM exercises with the client."

IF I did this and omitted 1&3, I would have gotten this SATA wrong.

Clearly, I am getting lost and/or distracted in reading this question. Any advise on how YOU read the above and your thought process... My hope is that, in sharing this example, I will gain some insight from the AN community to enhance my overall ability to read through wordy questions and not fall into the same"frustrated mind trap."

In advance thank you everyone for your thoughts,tips, and advise.

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Specializes in LTC.

Okay in a nutshell: the question isn't really about ROM that's why those responses were incorrect, the question asked what should be included in the teaching session for a family of a recent quadriplegic patient. making 1&3 things that would be included in that teaching session.

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They asked about the NEED to do ROM. Some people would choose #2, because it almost relates to why you have to do range of motion and pressure relief (part of ROM in SCI is for pressure relief). But with SCI, q2h isn't often enough, because tissue injury can occur in 15-20 minutes of unrelieved pressure.

(Also, sheepskin pads are not that great for pressure relief in the seat of a chair. A good seating system includes a cushion made for the purpose; these cost anywhere from $125 - $400 and have to be replaced annually at least.)

I'm thinking, another suboptimal question that if it were really in the NCLEX would probably be removed.

Also, be sure to choose your study materials to include those that give the rationales for the correct answers AND the reasons the incorrect ones are wrong.

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Okay in a nutshell: the question isn't really about ROM that's why those responses were incorrect, the question asked what should be included in the teaching session for a family of a recent quadriplegic patient. making 1&3 things that would be included in that teaching session.

Thank you for your response @hiswife0223...

A nurse is providing education to the family of a client scheduled for discharge. The client, who has severe cognitive impairments, is a recent quadriplegic. The family has questions about the need to perform range-of-motion of exercises with the client. What information should the teaching session include? Select all that apply.

So the underlined/bold sentence in this example is purely a distractor? Any tips on how to identify distractors (in general).

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They asked about the NEED to do ROM. Some people would choose #2, because it almost relates to why you have to do range of motion and pressure relief (part of ROM in SCI is for pressure relief). But with SCI, q2h isn't often enough, because tissue injury can occur in 15-20 minutes of unrelieved pressure.

(Also, sheepskin pads are not that great for pressure relief in the seat of a chair. A good seating system includes a cushion made for the purpose; these cost anywhere from $125 - $400 and have to be replaced annually at least.)

I'm thinking, another suboptimal question that if it were really in the NCLEX would probably be removed.

Also, be sure to choose your study materials to include those that give the rationales for the correct answers AND the reasons the incorrect ones are wrong.

Thank you for replying @GrnTea. I was hoping my post would catch your attention. I did read the rationales and they are subtly included in my original post. I am hopeful to gain some insight and/or tips on how to better identify distractors in questions. Also, I just wanted to thank you for the additional notes your throw into your posts. They are very helpful.

The full rationale I received stated:

The use of sheepskin padding in the bedand wheelchair will reduce friction. A paralyzed client, who may beunable to assist with position changes, has an increased risk of skinloss due to friction and shear. Skin and underlying structures maybecome anoxic after less than 2 hours of unrelieved pressure. Thirtydegrees from the head of the bed is the most therapeutic angle ofpositioning. The family should perform range-of-motion exercisesevery time they reposition the client

Thank you again for all of your help

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Yea so basically the question was really asking what would the nurse include in her discharge teaching for the family of a pt in a wheelchair with plegia. She can still address their concerns about ROM but the focus is what all is she gona include in the plan before they leave that will cover pt management. Thanks for posting this it was a good one!!

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