Mobility - Nursing Test Questions

Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 13 Mobility
The Concept of Mobility
1) During the assessment of a client, the nurse finds that the client's lower extremities are both
warm, sensation is intact, and motion is unrestricted. What does this finding suggest to the nurse?
A) Skeletal muscle attached to bones via tendons is performing correctly.
B) Smooth muscle attached to bones via ligaments will require further assessment.
C) Cartilage connecting bones has a good blood supply.
D) Muscle connecting the axial skeleton is compromised.
Answer: A
Explanation: A) Contraction of skeletal muscle attached to bones via tendons creates movement.
Smooth muscle is not attached to bones. Cartilage is not vascular. The axial skeleton is not part
of the lower extremities.
B) Contraction of skeletal muscle attached to bones via tendons creates movement. Smooth
muscle is not attached to bones. Cartilage is not vascular. The axial skeleton is not part of the
lower extremities.
C) Contraction of skeletal muscle attached to bones via tendons creates movement. Smooth
lower extremities.
D) Contraction of skeletal muscle attached to bones via tendons creates movement. Smooth
lower extremities.
Page Ref: 820
Cognitive Level: Creating
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
Learning Outcome: 1. Summarize the physiology of the musculoskeletal system related to
mobility.
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2) A 70-year-old client is diagnosed with bone spurs of the vertebral column. The nurse should
plan which priority action?
A) Implement low-level exercise program.
B) Assess pain management.
C) Teach relaxation techniques.
D) Refer to a dietitian.
Answer: B
Explanation: A) Osteoarthritis seen in normal aging can lead to the formation of bone spurs that
make movement painful. The nurse should assess pain management prior to implementing an
exercise program, teaching relaxation exercises, or referring to a dietitian.
B) Osteoarthritis seen in normal aging can lead to the formation of bone spurs that make
movement painful. The nurse should assess pain management prior to implementing an exercise
program, teaching relaxation exercises, or referring to a dietitian.
C) Osteoarthritis seen in normal aging can lead to the formation of bone spurs that make
D) Osteoarthritis seen in normal aging can lead to the formation of bone spurs that make
Page Ref: 824
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Learning Outcome: 2. Examine the relationship between mobility and other concepts/systems.
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3) A preadolescent patient who fell from a balance beam in Physical Education class reports
ankle pain. The nurse assesses edema and ecchymosis. What initial cause and intervention will
be anticipated?
A) Neurological evaluation for Parkinson's disease
B) Rest, ice, compression and elevation (RICE) for ankle sprain.
C) Brace fitting for scoliosis
D) Colchicine for gout
Answer: B
Explanation: A) RICE is used to decrease swelling and pain for ankle sprain. Parkinson's disease
usually presents with tremors in clients over 50. Scoliosis is an abnormal curvature of the spine.
There is no information suggesting scoliosis. Gout affecting mobility is caused by uric acid
buildup, usually in a joint in the toe.
B) RICE is used to decrease swelling and pain for ankle sprain. Parkinson's disease usually
presents with tremors in clients over 50. Scoliosis is an abnormal curvature of the spine. There is
no information suggesting scoliosis. Gout affecting mobility is caused by uric acid buildup,
usually in a joint in the toe.
C) RICE is used to decrease swelling and pain for ankle sprain. Parkinson's disease usually
D) RICE is used to decrease swelling and pain for ankle sprain. Parkinson's disease usually
Page Ref: 827
Learning Outcome: 3. Identify commonly occurring alterations in mobility and their related
therapies.
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4) The nurse detects an exaggerated concave curvature of the lumbar spine of a client. Which
conclusion about this assessment is correct?
A) Abnormal kyphosis is noted during range-of-motion assessment of a child.
B) Normal scoliosis is observed during the joint assessment of an older man.
C) Lordosis is commonly seen in the gait and posture assessment of a pregnant woman.
D) Crepitus is commonly found during the assessment interview of a middle-aged woman.
Answer: C
Explanation: A) An exaggerated concave curvature of the lumbar spine is lordosis and is seen in
the gait and posture assessment of pregnant women or obese clients. Scoliosis is not normal. A
range-of-motion assessment, joint assessment, or interview will not detect lordosis.
B) An exaggerated concave curvature of the lumbar spine is lordosis and is seen in the gait and
posture assessment of pregnant women or obese clients. Scoliosis is not normal. A range-of-
motion assessment, joint assessment, or interview will not detect lordosis.
C) An exaggerated concave curvature of the lumbar spine is lordosis and is seen in the gait and
D) An exaggerated concave curvature of the lumbar spine is lordosis and is seen in the gait and
Page Ref: 830
Learning Outcome: 4. Differentiate common assessment procedures used to examine
musculoskeletal health across the life span.
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5) An older client is demonstrating signs of osteoporosis. The nurse should instruct the client on
which tests to aid in the diagnosis of this disorder?
Select all that apply.
A) Magnetic resonance imaging
B) Dual energy x-ray absorptiometry
C) Bone mineral density
D) Quantitative ultrasound
E) Computed tomography
Answer: B, C, D
Explanation: A) Tests used to aid in the diagnosis of osteoporosis include dual energy x-ray
absorptiometry, quantitative ultrasound, and bone mineral density. Computed tomography and
magnetic resonance imaging are done to aid in the diagnosis of arthritis, intervertebral disk
disease, musculoskeletal trauma, muscle tears, osteomyelitis, and bone tumors.
B) Tests used to aid in the diagnosis of osteoporosis include dual energy x-ray absorptiometry,
quantitative ultrasound, and bone mineral density. Computed tomography and magnetic
resonance imaging are done to aid in the diagnosis of arthritis, intervertebral disk disease,
musculoskeletal trauma, muscle tears, osteomyelitis, and bone tumors.
C) Tests used to aid in the diagnosis of osteoporosis include dual energy x-ray absorptiometry,
D) Tests used to aid in the diagnosis of osteoporosis include dual energy x-ray absorptiometry,
E) Tests used to aid in the diagnosis of osteoporosis include dual energy x-ray absorptiometry,
Page Ref: 835-836
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Nursing Process: Implementation
Learning Outcome: 5. Describe diagnostic and laboratory tests to determine the individual's
mobility status.
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6) A 78-year-old client hospitalized with spinal fusion surgery has a BMI of 34. Chronologically
organize interventions to minimize the effects of bed rest.
1. Active range-of-motion exercises
2. Ambulation
3. Passive range-of-motion exercises
4. Resistive exercises
5. Weight loss instruction
Answer: 3, 1, 4, 2, 5
Explanation: If the muscles needed for walking have not been used, ambulation is accomplished
in steps. The first step is passive range-of-motion (ROM) exercises performed by the nurse or
therapist. Active ROM is performed by the patient. Next, resistive exercise engages muscles.
These steps prepare the client for ambulation. Nutrition instruction for weight loss would be
performed prior to discharge.
Page Ref: 837
Learning Outcome: 6. Explain management of musculoskeletal health and prevention of
immobility.
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7) The mother of a preadolescent client is concerned because the child often reports non-specific
"bone pain." What can the nurse respond to this mother?
A) "Bone pain in children is caused from the pulling of muscles when bones grow quickly."
B) "The child needs to rest more when the bones hurt."
C) "Non-specific bone pain means there is a disease process somewhere else in the body."
D) "It is a symptom that needs further investigation and will be reported to the physician."
Answer: A
Explanation: A) The rapid bone growth of childhood may lead to "growing pains" as muscles
are pulled when bones grow quickly. Non-specific bone pain in a child is not a symptom that
needs further investigation and does not need to be reported to the physician. Bone pain does not
mean that the child needs to rest more. Non-specific bone pain does not mean that there is a
disease process somewhere else in the body.
B) The rapid bone growth of childhood may lead to "growing pains" as muscles are pulled when
bones grow quickly. Non-specific bone pain in a child is not a symptom that needs further
investigation and does not need to be reported to the physician. Bone pain does not mean that the
child needs to rest more. Non-specific bone pain does not mean that there is a disease process
somewhere else in the body.
C) The rapid bone growth of childhood may lead to "growing pains" as muscles are pulled when
D) The rapid bone growth of childhood may lead to "growing pains" as muscles are pulled when
Page Ref: 820
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in mobility.
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8) The nurse is giving discharge instructions on removing loose rugs in the home to a client with
a total hip replacement. This is an example of which type of nursing intervention?
A) Independent: injury prevention
B) Independent: preservative functioning
C) Collaborative: promotion of comfort
D) Collaborative: family instruction
Answer: A
Explanation: A) Instructing the patient to remove loose rugs in the home is an example of an
independent nursing intervention aimed at injury prevention. Collaborative interventions involve
another discipline–e.g., physical therapy. Preservative functioning interventions are collaborative
efforts to limit the adverse effects of immobility. Promotion of comfort may involve pain
medication or padding a splint. Although the family should be included in this instruction, it is
not just directed at them.
B) Instructing the patient to remove loose rugs in the home is an example of an independent
nursing intervention aimed at injury prevention. Collaborative interventions involve another
discipline–e.g., physical therapy. Preservative functioning interventions are collaborative efforts
to limit the adverse effects of immobility. Promotion of comfort may involve pain medication or
padding a splint. Although the family should be included in this instruction, it is not just directed
at them.
C) Instructing the patient to remove loose rugs in the home is an example of an independent
at them.
D) Instructing the patient to remove loose rugs in the home is an example of an independent
at them.
Page Ref: 837
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in mobility.
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9) A 68-year-old client has decreased bone density. Which diagnostic test results will alert you to
the need for dietary education?
A) High calcitonin levels
B) High creatine kinase (CK) levels
C) Low phosphorus (P) levels
D) High growth hormone (GH) levels
Answer: C
Explanation: A) Low phosphorus levels may indicate a lack of vitamin D, which is affected by
diet. High CK levels occur after muscle damage. High growth hormone levels may indicate
acromegaly or gigantism. High calcitonin levels may indicate a parathyroid tumor.
B) Low phosphorus levels may indicate a lack of vitamin D, which is affected by diet. High CK
levels occur after muscle damage. High growth hormone levels may indicate acromegaly or
gigantism. High calcitonin levels may indicate a parathyroid tumor.
C) Low phosphorus levels may indicate a lack of vitamin D, which is affected by diet. High CK
D) Low phosphorus levels may indicate a lack of vitamin D, which is affected by diet. High CK
Page Ref: 835
Client Need Sub: Reduction of Risk Potential
Nursing Process: Analysis
Learning Outcome: 4. Differentiate common assessment procedures used to examine
musculoskeletal health across the life span.
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10) A 34-year-old mother of three sustained a right distal radial fracture and a left tibia fracture.
The nurse and physical therapist will teach the client to use which mobility aide(s)?
A) Lofstrand crutches
B) Platform crutches
C) Walker
D) Axillary crutches
Answer: B
Explanation: A) Platform crutches are used for clients who are unable to bear weight on their
wrists. A walker, axillary crutches, and Lofstrand crutches all require the use of the wrists.
B) Platform crutches are used for clients who are unable to bear weight on their wrists. A walker,
axillary crutches, and Lofstrand crutches all require the use of the wrists.
C) Platform crutches are used for clients who are unable to bear weight on their wrists. A walker,
D) Platform crutches are used for clients who are unable to bear weight on their wrists. A walker,
Page Ref: 838
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
Nursing Process: Implementation/Teaching and Learning
Learning Outcome: 7. Demonstrate the nursing process in providing culturally competent and
caring interventions across the life span for individuals with common alterations in mobility.
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11) The nurse contacts the provider to question an order to administer 1,000 mg aspirin to which
clients?
A) 68-year-old client for hand pain who has rheumatoid arthritis
B) 5-year-old client for ankle pain after a fall from a horse
C) 38-year-old client for headache pain after a skiing accident
D) 70-year-old client for back pain after laminectomy
E) 22-year-old client for knee pain who is allergic to naproxen
Answer: B, C, D, E
Explanation: A) Aspirin is indicated for clients with rheumatoid arthritis who have no other
contraindications. The healthcare provider should be questioned when ordering aspirin for a
child or for clients with a risk of bleeding. A fall, a skiing accident, and laminectomy surgery all
cause a risk of bleeding. Aspirin should not be given to a client who is allergic to non-steroidal
anti-inflammatory drugs.
B) Aspirin is indicated for clients with rheumatoid arthritis who have no other contraindications.
The healthcare provider should be questioned when ordering aspirin for a child or for clients
with a risk of bleeding. A fall, a skiing accident, and laminectomy surgery all cause a risk of
bleeding. Aspirin should not be given to a client who is allergic to non-steroidal anti-
inflammatory drugs.
C) Aspirin is indicated for clients with rheumatoid arthritis who have no other contraindications.
inflammatory drugs.
D) Aspirin is indicated for clients with rheumatoid arthritis who have no other contraindications.
inflammatory drugs.
E) Aspirin is indicated for clients with rheumatoid arthritis who have no other contraindications.
inflammatory drugs.
Page Ref: 838
Client Need Sub: Pharmacological and Parenteral Therapies
Learning Outcome: 8. Compare and contrast common independent and collaborative
interventions for clients with alterations in mobility.
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Exemplar 13.1 Back Problems
1) A client reports a sudden onset of right gluteal burning, tingling, and numbness with severity
9/10. You anticipate which priority action?
A) Continue the symptom interview to assess for bowel, bladder, and sexual function.
B) Obtain a surgical consult for possible cauda equina syndrome.
C) Request a physical therapy evaluation for function and strength.
D) Initiate client teaching on proper body mechanics and lifting.
Answer: A
Explanation: A) An abrupt onset of neurologic symptoms requires further assessment to
determine the urgency of the condition. Continuing the symptom interview will reveal pertinent
details of a possible neurologic emergency. Cauda equina syndrome is a rare medical emergency
with the symptoms of urinary incontinence, sexual dysfunction, or paralysis. Physical therapy
referral and body mechanic teaching are not indicated at this time.
B) An abrupt onset of neurologic symptoms requires further assessment to determine the urgency
of the condition. Continuing the symptom interview will reveal pertinent details of a possible
neurologic emergency. Cauda equina syndrome is a rare medical emergency with the symptoms
of urinary incontinence, sexual dysfunction, or paralysis. Physical therapy referral and body
mechanic teaching are not indicated at this time.
C) An abrupt onset of neurologic symptoms requires further assessment to determine the urgency
of the condition. Continuing the symptom interview will reveal pertinent details of a possible
neurologic emergency. Cauda equina syndrome is a rare medical emergency with the symptoms
of urinary incontinence, sexual dysfunction, or paralysis. Physical therapy referral and body
mechanic teaching are not indicated at this time.
D) An abrupt onset of neurologic symptoms requires further assessment to determine the
urgency of the condition. Continuing the symptom interview will reveal pertinent details of a
possible neurologic emergency. Cauda equina syndrome is a rare medical emergency with the
symptoms of urinary incontinence, sexual dysfunction, or paralysis. Physical therapy referral and
body mechanic teaching are not indicated at this time.
Page Ref: 841
Learning Outcome: 1. Describe the pathophysiology, etiology, clinical manifestations, and
direct and indirect causes of back problems.
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2) During a health screening, the nurse analyzes that which client is at the highest risk for back
problems?
A) 45-year-old man who plays golf three times a week for 20 years
B) 18-year-old girl who is a distance track runner since middle school
C) 62-year-old heavy truck mechanic with a body mass index (BMI) of 30
D) 12-year-old boy with a history of cerebral palsy with a BMI of 21
E) 78-year-old man with a 40 pack-year smoking history who is recently widowed
Answer: C, D, E
Explanation: A) Herniated intervertebral disks are more common in clients who are men, over
age 50, smokers, and obese, and who experience regular heavy lifting. Adolescent boys between
the ages of 9 and 15 are at greatest risk for developing scoliosis. Playing golf and running track
do not cause a high risk of back problems.
B) Herniated intervertebral disks are more common in clients who are men, over age 50,
smokers, and obese, and who experience regular heavy lifting. Adolescent boys between the ages
of 9 and 15 are at greatest risk for developing scoliosis. Playing golf and running track do not
cause a high risk of back problems.
C) Herniated intervertebral disks are more common in clients who are men, over age 50,
D) Herniated intervertebral disks are more common in clients who are men, over age 50,
E) Herniated intervertebral disks are more common in clients who are men, over age 50,
Page Ref: 841
Learning Outcome: 2. Identify risk factors and prevention methods associated with back
problems.
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3) A preadolescent patient is recovering from spinal fusion surgery for scoliosis. Which
interventions would be appropriate related to movement restrictions and pain?
A) Reposition every 2 hours.
B) Monitor intake and output.
C) Encourage and assist with ROM exercises every 4 hours while awake.
D) Administer pain medication around the clock.
E) Encourage incentive spirometer use every 4 hours while awake.
Answer: A, C, D
Explanation: A) Interventions appropriate for a preadolescent patient recovering from spinal
fusion to address Impaired Physical Mobility related to movement restrictions and pain would
include repositioning every 2 hours, encouraging and assisting with ROM exercises every 4
hours while awake, and administering pain medication around the clock. The use of an incentive
spirometer would be applicable for Impaired Tissue Perfusion. Monitoring intake and output
would be applicable for either Fluid Volume Excess or Deficit.
B) Interventions appropriate for a preadolescent patient recovering from spinal fusion to address
Impaired Physical Mobility related to movement restrictions and pain would include
repositioning every 2 hours, encouraging and assisting with ROM exercises every 4 hours while
awake, and administering pain medication around the clock. The use of an incentive spirometer
would be applicable for Impaired Tissue Perfusion. Monitoring intake and output would be
applicable for either Fluid Volume Excess or Deficit.
C) Interventions appropriate for a preadolescent patient recovering from spinal fusion to address
D) Interventions appropriate for a preadolescent patient recovering from spinal fusion to address
E) Interventions appropriate for a preadolescent patient recovering from spinal fusion to address
Page Ref: 845
Learning Outcome: 3. Illustrate the nursing process in providing culturally competent care
across the life span for individuals with back problems.
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4) A 56-year-old client has returned from post-anesthesia recovery after herniated disk surgery.
Prioritize nursing diagnoses based on the assessment findings below.
1. Moaning with pain rated 6/10
2. Two cm drainage on dressing
3. Spouse crying at bedside
4. Bilateral heels reddened
5. Oxygen saturation 88%
Answer: 5, 1, 3, 4, 2
Explanation: Ineffective Tissue Perfusion as evidenced by a pulse oximetry of 88% is the
priority nursing diagnosis. Acute Pain Management would also be a high priority. Caregiver
Role Strain is next in precedence. Explaining your assessments and actions will help reassure the
spouse. Repositioning the client's heels will prevent skin breakdown. The drainage is not
excessive or saturating the dressing.
Page Ref: 844
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with
back problems.
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5) The nurse is planning care for a client with acute back pain who is a single mother of two
small children and works part-time as a receptionist. What should be included in this patient's
care?
A) Instruct in appropriate body mechanics for lifting and ways to modify the work environment.
B) Suggest that the patient take time off from work until the back is healed.
C) Obtain an order for non-steroidal anti-inflammatory drugs (NSAIDs) from the client's primary
provider.
D) Suggest that the children be taken care of by an extended family member until the back is
healed.
Answer: A
Explanation: A) The patient is at risk for Ineffective Self Health Management, as she has two
small children that need care and a part-time job that is sedentary. The nurse should include
instructions in appropriate body mechanics for lifting and ways to modify the work environment.
The patient may or may not be prescribed NSAIDs. Suggesting that the patient take time off
from work or have extended family members care for the children may or may not be appropriate
and should not be included in this patient's plan of care.
B) The patient is at risk for Ineffective Self Health Management, as she has two small children
that need care and a part-time job that is sedentary. The nurse should include instructions in
appropriate body mechanics for lifting and ways to modify the work environment. The patient
may or may not be prescribed NSAIDs. Suggesting that the patient take time off from work or
have extended family members care for the children may or may not be appropriate and should
not be included in this patient's plan of care.
C) The patient is at risk for Ineffective Self Health Management, as she has two small children
D) The patient is at risk for Ineffective Self Health Management, as she has two small children
Page Ref: 845
Nursing Process: Planning
Learning Outcome: 6. Plan evidence-based care for an individual with back problems and his or
her family in collaboration with other members of the healthcare team.
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6) You are evaluating the postoperative outcomes of a 70 kg client who is post-op day 1 after
spinal fusion surgery. Which outcome(s) are not expected?
A) The client lying prone and using patient controlled analgesia every 12 hours
B) Urine output is 35 ml per hour and bowel sounds are present in all 4 quadrants.
C) The client is using incentive spirometer every 2 hours and verbalizes worry regarding ability
to function at work.
D) Dorsiflexion of the toes is present bilaterally and the client voided 7 hours after surgery.
Answer: A
Explanation: A) Lying prone is not an expected outcome. Using pain medicine as infrequently
as every 12 hours is also highly questionable on postoperative day 1 of spinal fusion surgery.
Expected outcomes include a urine output of 0.5 ml/kg body weight, use of an incentive
spirometer every 2 hours, verbalizing fears, dorsiflexion of the toes, and voiding within 8 hours
of surgery.
B) Lying prone is not an expected outcome. Using pain medicine as infrequently as every 12
hours is also highly questionable on postoperative day 1 of spinal fusion surgery. Expected
outcomes include a urine output of 0.5 ml/kg body weight, use of an incentive spirometer every 2
hours, verbalizing fears, dorsiflexion of the toes, and voiding within 8 hours of surgery.
C) Lying prone is not an expected outcome. Using pain medicine as infrequently as every 12
D) Lying prone is not an expected outcome. Using pain medicine as infrequently as every 12
Page Ref: 846
Cognitive Level: Evaluating
Nursing Process: Evaluation
Learning Outcome: 7. Evaluate expected outcomes for an individual with back problems.
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7) The nurse is documenting the interdisciplinary team report on a 13-year-old male client who
has a 35-degree Cobb angle confirmed by x-ray. Which plan of care is most appropriate?
A) Physical therapy consult prior to surgical intervention
B) Maintain the existing curvature with no increase.
C) Bracing for 12-23 hours per day and support group referral
D) Non-opioid analgesics and TLSO or Milwaukee brace
E) Instruction on exercises and support group referral
Answer: C, D, E
Explanation: A) Treatment of children with a Cobb angle between 25 and 45 degrees consists of
bracing for 12-23 hours per day with a TLSO or Milwaukee brace, mild pain medication,
counseling or support group referral, and exercise to improve posture and maintain or increase
spine flexibility. Mild scoliosis is observed every 3-6 months. Severe scoliosis requires surgical
intervention and subsequent physical therapy. Calcium supplements are not indicated for
scoliosis. Support groups or counseling is suggested for clients with moderate or severe scoliosis
or as needed.
B) Treatment of children with a Cobb angle between 25 and 45 degrees consists of bracing for
12-23 hours per day with a TLSO or Milwaukee brace, mild pain medication, counseling or
support group referral, and exercise to improve posture and maintain or increase spine flexibility.
Mild scoliosis is observed every 3-6 months. Severe scoliosis requires surgical intervention and
subsequent physical therapy. Calcium supplements are not indicated for scoliosis. Support
groups or counseling is suggested for clients with moderate or severe scoliosis or as needed.
C) Treatment of children with a Cobb angle between 25 and 45 degrees consists of bracing for
D) Treatment of children with a Cobb angle between 25 and 45 degrees consists of bracing for
E) Treatment of children with a Cobb angle between 25 and 45 degrees consists of bracing for
Page Ref: 849
Client Need Sub: Management of Care
Learning Outcome: 5. Summarize therapies used by interdisciplinary teams in the collaborative
care of an individual with back problems.
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8) A client with chronic pain from herniated intervertebral disks is experiencing constipation.
What interventions would be appropriate for this client?
A) Restrict foods high in fiber.
B) Avoid the use of stool softeners.
C) Encourage fluid intake of 2,500-3,000 ml each day.
D) Medicate for pain around the clock.
Answer: C
Explanation: A) A client with a herniated intervertebral disk could have problems with
constipation because of reduced mobility. Interventions to alleviate and prevent constipation
include encouraging fluid intake of 2,500-3,000 ml each day. Foods high in fiber should be
encouraged. Stool softeners are an option for clients who cannot tolerate a high-fiber diet.
Medicating for pain around the clock can exacerbate constipation, as most pain medications have
constipation as a side effect.
B) A client with a herniated intervertebral disk could have problems with constipation because of
reduced mobility. Interventions to alleviate and prevent constipation include encouraging fluid
intake of 2,500-3,000 ml each day. Foods high in fiber should be encouraged. Stool softeners are
an option for clients who cannot tolerate a high-fiber diet. Medicating for pain around the clock
can exacerbate constipation, as most pain medications have constipation as a side effect.
C) A client with a herniated intervertebral disk could have problems with constipation because of
D) A client with a herniated intervertebral disk could have problems with constipation because of
Page Ref: 843
Learning Outcome: 8. Employ evidence-based caring interventions for an individual with back
problems.
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9) The school nurse is conducting a screening on back safety for a small classroom of 6th grade
children. She brings a scale and weighs all the children and their backpacks behind a screen for
privacy. John weighs 40 kg and his backpack weighs 8 kg. Which intervention is appropriate for
this client?
A) Tell the student that the backpack is not too heavy for his weight.
B) Budget for rolling backpacks for all the students.
C) Explain the risks of heavy backs and alternatives to the student's parents.
D) Tell the student that he must take some items out of the backpack.
Answer: C
Explanation: A) If possible, backpacks should weigh no more than 10% of the child's body
weight. This child's backpack weighs 20% of his body weight, increasing his risks for alterations
in the alignment of the spinal column as well as significant pain. The best intervention would be
to explain the risk of heavy backpacks and the alternatives to the student's parents. Although
rolling backpacks are a viable alternative to decrease the risk of back injury, it may not be
feasible to budget these for all the students. Telling the student he must take items out of the
backpack has a low probability for success.
B) If possible, backpacks should weigh no more than 10% of the child's body weight. This
child's backpack weighs 20% of his body weight, increasing his risks for alterations in the
alignment of the spinal column as well as significant pain. The best intervention would be to
explain the risk of heavy backpacks and the alternatives to the student's parents. Although rolling
backpacks are a viable alternative to decrease the risk of back injury, it may not be feasible to
budget these for all the students. Telling the student he must take items out of the backpack has a
low probability for success.
C) If possible, backpacks should weigh no more than 10% of the child's body weight. This
D) If possible, backpacks should weigh no more than 10% of the child's body weight. This
Page Ref: 840
Learning Outcome: 2. Identify risk factors and prevention methods associated with back
problems.
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10) On the first postoperative day after spinal fusion, the nurse assesses a client and finds
temperature 39.2°C, blood pressure 100/50 mm/Hg, heart rate 118 bpm, and respirations 23/min.
Drainage at the incision site is clear and tests positive for glucose. Which assessment parameter
indicates the highest risk for surgical wound infection?
A) Temperature
B) Incisional drainage positive for glucose
C) Heart rate 118 bpm
D) Presence of incisional drainage
Answer: B
Explanation: A) Presence of glucose in the incisional drainage is indicative of cerebrospinal
fluid (CSF). A leak of CSF increases the risk of infection of the surgical site and meninges.
Temperature above 38°C is a fever. Fever may be a sign of infection anywhere in the body, not
just at the surgical wound site. Heart rate could also be elevated for numerous reasons. Purulent
drainage suggests wound infection. Clear drainage from a spinal incision is a sign of possible
infection.
B) Presence of glucose in the incisional drainage is indicative of cerebrospinal fluid (CSF). A
leak of CSF increases the risk of infection of the surgical site and meninges. Temperature above
38°C is a fever. Fever may be a sign of infection anywhere in the body, not just at the surgical
wound site. Heart rate could also be elevated for numerous reasons. Purulent drainage suggests
wound infection. Clear drainage from a spinal incision is a sign of possible infection.
C) Presence of glucose in the incisional drainage is indicative of cerebrospinal fluid (CSF). A
D) Presence of glucose in the incisional drainage is indicative of cerebrospinal fluid (CSF). A
Page Ref: 846
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11) The mother of a 12-year-old client meets with the school nurse to discuss her daughter's
recent diagnosis of scoliosis. She shares that she is worried that her daughter wants to start home
schooling because she has been fitted with a brace. Which interventions will support the nursing
diagnosis of Disturbed Body Image related to deformity and brace?
A) Include the student and family in a meeting to elicit her feelings about scoliosis and wearing a
brace.
B) Offer to arrange a meeting for the student with an 8th grader who has scoliosis.
C) Encourage the student and family to register for home schooling and minimize risk of
ridicule.
D) Teach the student and family about clothing that will hide the brace.
E) Suggest that the pediatrician prescribe an anti-anxiety agent for the student.
Answer: A, B, D
Explanation: A) Important interventions for disturbed body image are attentive listening,
offering a support group or person, and teaching the student and family about clothes that will
hide the brace. Avoiding other children and community encounters will create a risk of social
isolation. There is not enough information to indicate a problem requiring pharmacologic
management.
B) Important interventions for disturbed body image are attentive listening, offering a support
group or person, and teaching the student and family about clothes that will hide the brace.
Avoiding other children and community encounters will create a risk of social isolation. There is
not enough information to indicate a problem requiring pharmacologic management.
C) Important interventions for disturbed body image are attentive listening, offering a support
D) Important interventions for disturbed body image are attentive listening, offering a support
E) Important interventions for disturbed body image are attentive listening, offering a support
Page Ref: 850
Nursing Process: Caring
Learning Outcome: 6. Plan evidence-based care for an individual with back problems and his or
22
12) During a home care visit, an 87-year-old client begins to cry softly when asked about how
she is coping with back pain. She states, "My back hurts bad all the time and I am so confused
about all these tests and scared that the doctor wants me to have surgery" Which priority caring
intervention is appropriate for this client?
A) Ask the client to rate pain on a scale of 1 to 10.
B) Explain procedures in a way the client will understand.
C) Educate on drug, then administer ordered pain medication.
D) Attentively listen to the client's thoughts and fears.
Answer: B
Explanation: A) The priority caring intervention in a client who is ready to disclose emotions is
to attentively listen to the client's thoughts and fears. Each of the other choices is appropriate at
some point on the care continuum.
B) The priority caring intervention in a client who is ready to disclose emotions is to attentively
listen to the client's thoughts and fears. Each of the other choices is appropriate at some point on
the care continuum.
C) The priority caring intervention in a client who is ready to disclose emotions is to attentively
the care continuum.
D) The priority caring intervention in a client who is ready to disclose emotions is to attentively
the care continuum.
Page Ref: 845
Nursing Process: Caring
23
Exemplar 13.2 Fractures
1) A client who sustained multiple fractures in a motor vehicle accident is at high risk of
osteomyelitis due to which fracture?
A) Avulsion
B) Open
C) Comminuted
D) Depression
Answer: B
Explanation: A) The highest risk for infection, osteomyelitis, is when bone breaks through the
skin in an open fracture. Comminuted, avulsion, and depression fractures are closed from the
environment and at less risk of infection.
B) The highest risk for infection, osteomyelitis, is when bone breaks through the skin in an open
fracture. Comminuted, avulsion, and depression fractures are closed from the environment and at
less risk of infection.
C) The highest risk for infection, osteomyelitis, is when bone breaks through the skin in an open
D) The highest risk for infection, osteomyelitis, is when bone breaks through the skin in an open
Page Ref: 854
direct and indirect causes of fractures.
24
2) The nurse is answering questions from participants after a presentation on preventing fractures
at an assisted-living facility. Which resident is at highest risk for the development of fractures?
A) The resident who participates in resistance training exercises 3 times a week and takes a
calcium supplement
B) The resident who hikes in the woods once a week and smokes 14 cigarettes per day
C) The resident who line dances twice a week and has a glass of wine with dinner
D) The resident who teaches yoga four times per week and is lactose-intolerant
Answer: B
Explanation: A) Among older clients, smoking is the highest-risk behavior. Although exercise
helps prevent fractures, hiking on an uneven surface can be a risk. Resistance training, line
dancing, yoga, and a calcium supplement can decrease the risk of fracture with a fall. A glass of
wine daily is not a risk factor for fracture from a fall. Lactose intolerance can lower calcium
intake, although there are other sources of dietary or supplemental calcium.
B) Among older clients, smoking is the highest-risk behavior. Although exercise helps prevent
fractures, hiking on an uneven surface can be a risk. Resistance training, line dancing, yoga, and
a calcium supplement can decrease the risk of fracture with a fall. A glass of wine daily is not a
risk factor for fracture from a fall. Lactose intolerance can lower calcium intake, although there
are other sources of dietary or supplemental calcium.
C) Among older clients, smoking is the highest-risk behavior. Although exercise helps prevent
D) Among older clients, smoking is the highest-risk behavior. Although exercise helps prevent
Page Ref: 857
Learning Outcome: 2. Identify risk factors and prevention methods associated with fractures.
25
3) The nurse is discharging a client after a fracture. You know this client has unsealed epiphyseal
plates, experienced a spiral fracture, and is active for the client's age. Which are the most
appropriate components of this discharge plan?
A) Teach on home safety related to fall prevention.
B) Refer to social worker for assessment related to family dynamics.
C) Refer to physical therapy for brace fitting.
D) Teach on medication to treat osteoporosis.
E) Teach on safety equipment for sports and play.
Answer: B, E
Explanation: A) Children have unsealed epiphyseal plates and experience spiral fractures. An
unexplained spiral fracture of a child should be investigated for potential child abuse. Any child
with a fracture should have teaching with parents on safe sports and play. A spiral fracture is not
associated with osteoporosis or requiring a brace. Teaching on home safety related to fall
prevention would be more appropriate for an older person.
B) Children have unsealed epiphyseal plates and experience spiral fractures. An unexplained
spiral fracture of a child should be investigated for potential child abuse. Any child with a
fracture should have teaching with parents on safe sports and play. A spiral fracture is not
C) Children have unsealed epiphyseal plates and experience spiral fractures. An unexplained
D) Children have unsealed epiphyseal plates and experience spiral fractures. An unexplained
E) Children have unsealed epiphyseal plates and experience spiral fractures. An unexplained
Page Ref: 857
Client Need: Psychosocial Integrity: Abuse or Neglect
across the life span for individuals with fractures.
26
4) A nurse is teaching a mother warning signs and symptoms to watch for in her child, who will
be discharged with a full leg cast. Which statement by the mother indicates that further teaching
is required?
A) "If her foot turns white and cold, I should call the call the physical therapist."
B) "I can expect she will have some pain that the medicine will help."
C) "We can use a blow drier on low to help with the itching."
D) "We can cut a hole in the cast if her foot swells until we get her to a doctor."
E) "It is ok that the plaster cast gets damp as long as I blow dry it."
Answer: A, D
Explanation: A) The parent will need additional teaching if the parent believes that it is
appropriate to call the physical therapist for a white, cold foot, get a plaster cast wet and blow
dry it, or cut a hole in a cast for swelling. The teaching is adequate for expectations of pain and
use of a blow drier to help with itching.
B) The parent will need additional teaching if the parent believes that it is appropriate to call the
physical therapist for a white, cold foot, get a plaster cast wet and blow dry it, or cut a hole in a
cast for swelling. The teaching is adequate for expectations of pain and use of a blow drier to
help with itching.
C) The parent will need additional teaching if the parent believes that it is appropriate to call the
help with itching.
D) The parent will need additional teaching if the parent believes that it is appropriate to call the
help with itching.
E) The parent will need additional teaching if the parent believes that it is appropriate to call the
help with itching.
Page Ref: 862
Learning Outcome: 6. Plan evidence-based care for an individual with a fracture and his or her
family in collaboration with other members of the healthcare team.
27
5) A client is admitted to your inpatient rehabilitation unit. (See exhibit.) The nurse formulates a
care plan with which priority diagnosis?
A) Risk for Peripheral Neurovascular Dysfunction related to disruption of traction weights

B) Risk for Infection related to surgical incision and insertion of hardware
C) Risk for Disuse Syndrome related to use of traction to stabilize fracture
D) Acute Pain related to bone and soft tissue damage
Answer: B
Explanation: A) Halo traction uses pins surgically implanted in the skull, which increases the
risk for infection. Acute pain is not as high a priority as the risk for meningitis. Risk for Disuse is
also an appropriate lower-priority diagnosis. Halo traction is not connected to weights.
B) Halo traction uses pins surgically implanted in the skull, which increases the risk for
infection. Acute pain is not as high a priority as the risk for meningitis. Risk for Disuse is also an
appropriate lower-priority diagnosis. Halo traction is not connected to weights.
C) Halo traction uses pins surgically implanted in the skull, which increases the risk for
D) Halo traction uses pins surgically implanted in the skull, which increases the risk for
Page Ref: 863
Learning Outcome: 4. Formulate priority nursing diagnoses appropriate for an individual with a
fracture.
28
6) The x-ray of a client 14 weeks post-ulnar fracture exhibits no callus formation. Which
collaborative action does the nurse anticipate?
A) The physical therapist will set up Buck traction.
B) The surgeon will order electromagnetic stimulation.
C) The pharmacist will educate the client on antibiotics.
D) The nurse will counsel the client on starting range-of-motion exercise.
Answer: B
Explanation: A) An ulnar fracture that does not show callus formation in 14 weeks is classified
as experiencing nonunion. Electromagnetic stimulation has been demonstrated to enhance
healing in circumstances of nonunion. Buck traction, antibiotics, and exercise are not indicated
for nonunion of a fracture.
B) An ulnar fracture that does not show callus formation in 14 weeks is classified as
experiencing nonunion. Electromagnetic stimulation has been demonstrated to enhance healing
in circumstances of nonunion. Buck traction, antibiotics, and exercise are not indicated for
nonunion of a fracture.
C) An ulnar fracture that does not show callus formation in 14 weeks is classified as
D) An ulnar fracture that does not show callus formation in 14 weeks is classified as
Page Ref: 861
care of an individual with a fracture.
29
7) Which evaluation data indicates that a positive outcome was met in a client who is being seen
for a 6-week follow-up status post a fracture associated with osteoporosis?
A) Greenstick fracture exhibits complete union on x-ray.
B) Twenty-pound weight loss has been accomplished since surgery.
C) Prophylactic corticosteroid treatment course completed
D) Physical therapy treatment course completed
Answer: B
Explanation: A) Completion of a prescribed course of physical therapy is an anticipated
outcome of a fracture associated with osteoporosis. A greenstick fracture is associated with the
soft bones of children. The weight loss may not be beneficial depending on the body mass index
at the time of the injury. Steroids are used to prevent fat emboli in fractures of the long bones.
B) Completion of a prescribed course of physical therapy is an anticipated outcome of a fracture
associated with osteoporosis. A greenstick fracture is associated with the soft bones of children.
The weight loss may not be beneficial depending on the body mass index at the time of the
injury. Steroids are used to prevent fat emboli in fractures of the long bones.
C) Completion of a prescribed course of physical therapy is an anticipated outcome of a fracture
D) Completion of a prescribed course of physical therapy is an anticipated outcome of a fracture
Page Ref: 867
Learning Outcome: 6. Plan evidence-based care for an individual with a fracture and his or her
family in collaboration with other members of the healthcare team.
30
8) The nurse in an orthopedic outpatient clinic expects to see several clients with fractures for
follow-up. After reviewing the clients' charts, which client is at the highest risk of delayed
union?
A) 20-year-old college student with type I diabetes mellitus who sustained a fractured tibia in a
bicycle accident. Nutrition recall tool completed during the last visit was consistent with
American Diabetic Association (ADA) guidelines.
B) 62-year-old bartender with a history of peptic ulcer who sustained a fractured clavicle
breaking up a fight at work. He was upset about abstaining from upper body resistance training.
C) 49-year-old teacher with osteoporosis who sustained an open ulnar fracture in a motor vehicle
accident. Reports that she has cut down smoking to 10 cigarettes per day.
D) 55-year-old accountant who sustained fractures to the 4th and 5th right metatarsals. He has a
history of hypertension under good control with medication.
Answer: C
Explanation: A) Evaluating risk of delayed union requires knowledge of the factors that impact
bone healing. The client at greatest risk of delayed union had the risks of an open fracture and
osteoporosis. She also used tobacco, which decreases blood supply to the healing bone. Although
diabetes does increase risk of delayed union, this client was young and exercised on a bicycle
prior to the accident. If he was following an ADA diet, he had adequate intake of vitamin D and
calcium, which fosters bone healing. Peptic ulcer or controlled hypertension is not a risk for
delayed bone healing.
B) Evaluating risk of delayed union requires knowledge of the factors that impact bone healing.
The client at greatest risk of delayed union had the risks of an open fracture and osteoporosis.
She also used tobacco, which decreases blood supply to the healing bone. Although diabetes
does increase risk of delayed union, this client was young and exercised on a bicycle prior to the
accident. If he was following an ADA diet, he had adequate intake of vitamin D and calcium,
which fosters bone healing. Peptic ulcer or controlled hypertension is not a risk for delayed bone
healing.
C) Evaluating risk of delayed union requires knowledge of the factors that impact bone healing.
healing.
31
D) Evaluating risk of delayed union requires knowledge of the factors that impact bone healing.
healing.
Page Ref: 861
direct and indirect causes of fractures.
32
9) A client hospitalized with an open reduction and internal fixation of a fractured femur reports
right calf pain. You note the right calf is 3.5 cm larger than the left calf with generalized
posterior erythema. The right calf is tender to touch. Dorsalis pedis pulse is 3/4+ bilaterally.
What is the nurse's next action?
A) Use a Doppler stethoscope to confirm pedal pulses.
B) Notify the healthcare provider of the findings.
C) Prepare to apply a cast to the right leg.
D) Prepare to administer intravenous heparin.
Answer: B
Explanation: A) These findings indicate a possible deep vein thrombosis. Notifying the
healthcare provider immediately is the first action after assessing these signs and symptoms. If
pedal pulse can be palpated, then a Doppler stethoscope is not needed. A Doppler ultrasound test
may be ordered by the provider. A cast is not indicated with internal fixation. Intravenous
heparin will likely be ordered after the condition is confirmed.
B) These findings indicate a possible deep vein thrombosis. Notifying the healthcare provider
immediately is the first action after assessing these signs and symptoms. If pedal pulse can be
palpated, then a Doppler stethoscope is not needed. A Doppler ultrasound test may be ordered by
the provider. A cast is not indicated with internal fixation. Intravenous heparin will likely be
ordered after the condition is confirmed.
C) These findings indicate a possible deep vein thrombosis. Notifying the healthcare provider
D) These findings indicate a possible deep vein thrombosis. Notifying the healthcare provider
Page Ref: 858
across the life span for individuals with fractures.
33
10) A client who is hospitalized after a left hip fracture is scheduled for surgery late this
afternoon. After receiving report, the nurse evaluates the Buck traction applied by a new physical
therapist. Which finding indicates that the traction is correctly applied?
A) Foam boot covers the right lower leg from the knee down.
B) 20-pound weights are connected to the bottom of a foam boot.
C) Weights are supported by a stool at the end of the bed.
D) The left knee and hip are in alignment above the foam boot.
Answer: D
Explanation: A) The correct placement of Buck traction permits the left knee and hip to align.
Buck traction is skin traction which does not tolerate heavy weights. Usually 5-pound weights
are used. Twenty-pound weights are used on skin traction. Weights always hang free from a
pulley and are never supported by a stool at the end of the bed. A foam boot covers the affected
leg, the left leg, not the right.
B) The correct placement of Buck traction permits the left knee and hip to align. Buck traction is
skin traction which does not tolerate heavy weights. Usually 5-pound weights are used. Twenty-
pound weights are used on skin traction. Weights always hang free from a pulley and are never
supported by a stool at the end of the bed. A foam boot covers the affected leg, the left leg, not
the right.
C) The correct placement of Buck traction permits the left knee and hip to align. Buck traction is
the right.
D) The correct placement of Buck traction permits the left knee and hip to align. Buck traction is
the right.
Page Ref: 863
Client Need Sub: Basic Care and Comfort
care of an individual with a fracture.
34
Exemplar 13.3 Hip Fractures
1) The nurse is presenting a program on surviving a fall at a senior center. Which statement
indicates that the participant needs clarification of the content on emergency hip fracture actions
after a fall?
A) "I should crawl to a phone on the affected side to keep it stable against a hard surface."
B) "I need to subscribe to an emergency call service like Lifeline."
C) "To call for help, I can scoot on my bottom to a low wall-mounted phone."
D) "If possible, I can crawl to a stairway and use the stairs to lift up to a standing position."
Answer: A
Explanation: A) Clients at risk for falls and hip fractures should be taught how to notify
emergency services in the event of a fall and injury. The client should turn onto the stomach and
crawl to the phone. The client should participate in a 24-hour emergency alert service such as
LifelineTM. The client can also scoot to the phone using their buttocks on the uninjured side.
And another option is to crawl to a stairway and use the stairs to gradually lift self to a standing
position.
B) Clients at risk for falls and hip fractures should be taught how to notify emergency services in
the event of a fall and injury. The client should turn onto the stomach and crawl to the phone.
The client should participate in a 24-hour emergency alert service such as LifelineTM. The client
can also scoot to the phone using their buttocks on the uninjured side. And another option is to
crawl to a stairway and use the stairs to gradually lift self to a standing position.
C) Clients at risk for falls and hip fractures should be taught how to notify emergency services in
D) Clients at risk for falls and hip fractures should be taught how to notify emergency services in
Page Ref: 870
Client Need Sub: Safety and Infection Control
Learning Outcome: 2. Identify risk factors and prevention methods associated with hip fractures.
35
2) The nurse is evaluating an older client in a long-term care facility after a fall. Which
assessment finding requires priority action?
A) The injured leg is shortened and externally rotated.
B) Redness and severe swelling are found at the hip joint.
C) Pain is relieved by moving the affected extremity.
D) The patient is repeatedly flexing the injured leg at the hip.
Answer: A
Explanation: A) The patient with a fractured hip is often in extreme pain and assumes a position
with the leg on the affected side shortened and externally rotated because of gravity and the pull
of the muscles. Any movement of the leg on the side of the affected hip is likely to cause severe
muscle spasms and further pain. Redness and swelling are the classic signs of inflammation not
immediately present after hip fracture. Extreme pain associated with hip fracture prevents any
voluntary movement in the leg.
B) The patient with a fractured hip is often in extreme pain and assumes a position with the leg
on the affected side shortened and externally rotated because of gravity and the pull of the
muscles. Any movement of the leg on the side of the affected hip is likely to cause severe muscle
spasms and further pain. Redness and swelling are the classic signs of inflammation not
C) The patient with a fractured hip is often in extreme pain and assumes a position with the leg
D) The patient with a fractured hip is often in extreme pain and assumes a position with the leg
Page Ref: 870
direct and indirect causes of hip fractures.
36
3) A postmenopausal client asks the nurse what she can do to prevent fracturing her hips, as her
mother and grandmother both experienced this health problem. What should the nurse instruct
this client?
A) Avoid exercise.
B) Do not smoke.
C) Limit sun exposure.
D) Use throw rugs throughout the home.
Answer: B
Explanation: A) The one modifiable risk factor for hip fractures is smoking. Women who smoke
have a greater risk because smoking reduces bone density in menopausal and postmenopausal
women. The client should not be instructed to avoid exercise; exercise will enhance the client's
gait, balance, and musculoskeletal strength. Limiting sun exposure will not impact the client's
risk of experiencing a hip fracture. The nurse should not instruct the client to use throw rugs
throughout the home because this could cause tripping, leading to a fall.
B) The one modifiable risk factor for hip fractures is smoking. Women who smoke have a
greater risk because smoking reduces bone density in menopausal and postmenopausal women.
The client should not be instructed to avoid exercise; exercise will enhance the client's gait,
balance, and musculoskeletal strength. Limiting sun exposure will not impact the client's risk of
experiencing a hip fracture. The nurse should not instruct the client to use throw rugs throughout
the home because this could cause tripping, leading to a fall.
C) The one modifiable risk factor for hip fractures is smoking. Women who smoke have a
D) The one modifiable risk factor for hip fractures is smoking. Women who smoke have a
Page Ref: 870
Learning Outcome: 2. Identify risk factors and prevention methods associated with hip fractures.
37
4) The first day after surgery to repair a fractured hip sustained from a fall, an older client refuses
to ambulate but says he will consider it tomorrow. Which is action is priority for the nurse?
A) Coordinate personnel to assist with ambulation.
B) Document the client's refusal.
C) Assess why the client is refusing to ambulate.
D) Notify the surgeon.
Answer: C
Explanation: A) The first thing the nurse should do is assess why the client is refusing to
ambulate. The client might be fearful of falling, which had already occurred and resulted in a
fractured hip. Once this is assessed, the nurse could plan interventions that would facilitate
ambulation, such as controlling pain and reducing the fear of falling. It is premature to notify the
surgeon. The nurse should not force the client to get out of bed. Documenting the client's refusal
to ambulate should be done after the reason for the refusal is known.
B) The first thing the nurse should do is assess why the client is refusing to ambulate. The client
might be fearful of falling, which had already occurred and resulted in a fractured hip. Once this
is assessed, the nurse could plan interventions that would facilitate ambulation, such as
controlling pain and reducing the fear of falling. It is premature to notify the surgeon. The nurse
should not force the client to get out of bed. Documenting the client's refusal to ambulate should
be done after the reason for the refusal is known.
C) The first thing the nurse should do is assess why the client is refusing to ambulate. The client
D) The first thing the nurse should do is assess why the client is refusing to ambulate. The client
Page Ref: 874
across the life span for individuals with hip fractures.
38
5) A client recovering from total hip replacement surgery is experiencing pain exacerbated with
movement and tells the nurse, "I have no idea how I can return home, as I live alone." The
client's BMI is 35. Which nursing diagnosis would be a priority for this client?
A) Imbalanced Nutrition: More than Body Requirements
B) Acute Pain
C) Impaired Physical Mobility
D) Ineffective Coping
Answer: B
Explanation: A) Unless pain is controlled, the client will not be able to participate in
interventions to address the Impaired Physical Mobility. The diagnoses of Ineffective Coping
and Imbalanced Nutrition can be addressed after Acute Pain and Impaired Physical Mobility
have been addressed.
B) Unless pain is controlled, the client will not be able to participate in interventions to address
the Impaired Physical Mobility. The diagnoses of Ineffective Coping and Imbalanced Nutrition
can be addressed after Acute Pain and Impaired Physical Mobility have been addressed.
C) Unless pain is controlled, the client will not be able to participate in interventions to address
D) Unless pain is controlled, the client will not be able to participate in interventions to address
Page Ref: 873
Nursing Process: Diagnosis
hip fractures.
39
6) The nurse is providing discharge instructions to an older client recovering from a fractured
hip. He is planning to stay with his son, who is included in the intervention. Which statement
would indicate good understanding of the instruction?
A) "I have signed a contract with Lifeline."
B) "We are replacing the carpet with laminate flooring."
C) "I've borrowed a toilet seat riser from the equipment closet."
D) "I will be sure to take oxycodone before I go downstairs in the morning."
E) "I can help out my son with housework while I'm staying."
Answer: A, C
Explanation: A) Use of an emergency alert service and using a toilet seat riser are both
statements that evidence good understanding of instruction. It is not necessary to replace
carpeting with laminate flooring, just to pick up loose area rugs. Pain medication should not be
taken when there is a risk of a fall, particularly down a set of stairs. The nurse should assess with
exactly which housework the client believes he can assist his son. Many housework tasks will be
inappropriate.
B) Use of an emergency alert service and using a toilet seat riser are both statements that
evidence good understanding of instruction. It is not necessary to replace carpeting with laminate
flooring, just to pick up loose area rugs. Pain medication should not be taken when there is a risk
of a fall, particularly down a set of stairs. The nurse should assess with exactly which housework
the client believes he can assist his son. Many housework tasks will be inappropriate.
C) Use of an emergency alert service and using a toilet seat riser are both statements that
D) Use of an emergency alert service and using a toilet seat riser are both statements that
E) Use of an emergency alert service and using a toilet seat riser are both statements that
Page Ref: 874
Learning Outcome: 6. Plan evidence-based care for an individual with a hip fracture and his or
40
7) The nurse is evaluating care provided to a client recovering from hip replacement surgery.
What would indicate that the client has achieved the expected outcome for pain management?
A) Medicating for pain with intramuscular injection every 4 hours
B) Client crying and requesting pain medication prior to morning care
C) Client using PCA pump around the clock for pain management
D) Providing pain medication prior to physical therapy
Answer: D
Explanation: A) Pain needs to be controlled so that the client can participate in physical therapy.
When pain medication is provided prior to physical therapy, the client's participation in therapy
is enhanced. The other statements indicate the client is still experiencing significant pain, which
would hinder participating in therapy and delay discharge.
B) Pain needs to be controlled so that the client can participate in physical therapy. When pain
medication is provided prior to physical therapy, the client's participation in therapy is enhanced.
The other statements indicate the client is still experiencing significant pain, which would hinder
participating in therapy and delay discharge.
C) Pain needs to be controlled so that the client can participate in physical therapy. When pain
D) Pain needs to be controlled so that the client can participate in physical therapy. When pain
Page Ref: 873
Learning Outcome: 7. Evaluate expected outcomes for an individual with a hip fracture.
41
8) An older client, diagnosed with a fractured hip, participates in golf and does home
maintenance activities. The nurse realizes that this client is a candidate for which surgical repair
procedure?
A) Total hip replacement
B) Open reduction and external fixation
C) Austin-Moore prosthesis
D) Open reduction and internal fixation
Answer: D
Explanation: A) The open reduction and internal fixation is the surgical preference to repair a
fractured hip for active elderly adults who are able to use crutches with partial weight bearing. A
total hip replacement is done only when severe arthritis is present. Austin-Moore prosthesis is
preferred for the less active older person. Open reduction and external fixation is not a surgical
option for a fractured hip.
B) The open reduction and internal fixation is the surgical preference to repair a fractured hip for
active elderly adults who are able to use crutches with partial weight bearing. A total hip
replacement is done only when severe arthritis is present. Austin-Moore prosthesis is preferred
for the less active older person. Open reduction and external fixation is not a surgical option for a
fractured hip.
C) The open reduction and internal fixation is the surgical preference to repair a fractured hip for
fractured hip.
D) The open reduction and internal fixation is the surgical preference to repair a fractured hip for
fractured hip.
Page Ref: 871
care of an individual with a hip fracture.
42
9) A client recovering from surgery to repair a fractured hip has a history of osteomyelitis. What
can the nurse do to reduce the client's risk for a postoperative infection?
A) Assess for pain every 1-2 hours.
B) Use sterile technique for dressing changes.
C) Assess wound for size, color, and drainage.
D) Administer antibiotics as prescribed.
E) Monitor for edema and swelling.
Answer: B, C, D
Explanation: A) Interventions to reduce the Risk for Infection include using sterile technique for
dressing changes, assessing the wound for size, color, and drainage, and administering antibiotics
as prescribed. Monitoring for edema and swelling and assessing for pain every 1-2 hours would
be appropriate if the client were at Risk for Peripheral Neurovascular Dysfunction.
B) Interventions to reduce the Risk for Infection include using sterile technique for dressing
changes, assessing the wound for size, color, and drainage, and administering antibiotics as
prescribed. Monitoring for edema and swelling and assessing for pain every 1-2 hours would be
appropriate if the client were at Risk for Peripheral Neurovascular Dysfunction.
C) Interventions to reduce the Risk for Infection include using sterile technique for dressing
D) Interventions to reduce the Risk for Infection include using sterile technique for dressing
E) Interventions to reduce the Risk for Infection include using sterile technique for dressing
Page Ref: 873
Learning Outcome: 8. Employ evidence-based caring interventions for an individual with hip
fractures.
43
10) A client is undergoing surgery for a fractured hip. The surgeon has expressed that careful
attention will be paid to preserving the epiphyseal plate. Which client will require this precaution
during surgery?
A) A post-menopausal paraplegic
B) A 32-year-old competitive body builder
C) A prepubescent girl who is a vegetarian
D) An 85-year-old woman with osteoporosis
Answer: C
Explanation: A) Epiphyseal plates are unique joints that produce growth of bone length in
children. There is an epiphyseal plate which lies between the head and neck of the femur that
must be preserved during surgery to obstruct bone growth. All the other clients were older than
18-25 years, when the epiphyseal plate closes.
B) Epiphyseal plates are unique joints that produce growth of bone length in children. There is
an epiphyseal plate which lies between the head and neck of the femur that must be preserved
during surgery to obstruct bone growth. All the other clients were older than 18-25 years, when
the epiphyseal plate closes.
C) Epiphyseal plates are unique joints that produce growth of bone length in children. There is
D) Epiphyseal plates are unique joints that produce growth of bone length in children. There is
Page Ref: 871
across the life span for individuals with hip fractures.
44
11) The nurse gives discharge instructions to a 57-year-old bicycle enthusiast who sustained a
fall and underwent open reduction and internal fixation of a fractured hip. Which of the
following client behaviors support that discharge teaching goals were met?
A) Gives a return demonstration of an abduction pillow with the wide end at the bottom of the
bed.
B) Backs with a walker until posterior thighs touch the seat of a low chair prior to sitting.
C) The client plans to drive to physical therapy appointment in 1 week.
D) Verbalizes pain of 3/10 on discharge from the hospital.
E) The client's daughter is present for all teaching.
Answer: A, D, E
Explanation: A) The abduction pillow maintains the legs apart by use of a triangular shape that
is wide at the feet and narrow at the groin when place between the legs of a supine client. Pain
management goal is for pain to be rated at no more than 3/10. Family members should be present
for discharge teaching if at all possible. The client should back with a walker into a high chair
prior to sitting. Excess flexion of the hip will place too much strain on the operative site. Driving
is prohibited for several weeks after hip surgery.
B) The abduction pillow maintains the legs apart by use of a triangular shape that is wide at the
feet and narrow at the groin when place between the legs of a supine client. Pain management
goal is for pain to be rated at no more than 3/10. Family members should be present for
discharge teaching if at all possible. The client should back with a walker into a high chair prior
to sitting. Excess flexion of the hip will place too much strain on the operative site. Driving is
prohibited for several weeks after hip surgery.
C) The abduction pillow maintains the legs apart by use of a triangular shape that is wide at the
D) The abduction pillow maintains the legs apart by use of a triangular shape that is wide at the
45
E) The abduction pillow maintains the legs apart by use of a triangular shape that is wide at the
Page Ref: 874
Learning Outcome: 7. Evaluate expected outcomes for an individual with a hip fracture.
46
Exemplar 13.4 Multiple Sclerosis
1) A client diagnosed with multiple sclerosis has an acute onset of visual changes, fatigue, and
leg weakness. The client says that the last time this happened, recovery occurred in a few weeks.
Which classification of multiple sclerosis is the client experiencing?
A) Progressive-relapsing
B) Secondary-progressive
C) Relapsing-remitting
D) Primary-progressive
Answer: C
Explanation: A) There are four classifications of multiple sclerosis. The client has an
exacerbation of symptoms and has a history of full recovery. This is classified as relapsing-
remitting and is the most common type. Primary-progressive is a steady worsening of the disease
with occasional minor recovery. Secondary-progressive begins as relapsing-remitting but the
disease becomes worse between exacerbations. Progressive-relapsing is rare, with the disease
progressing from the onset with periods of exacerbation.
B) There are four classifications of multiple sclerosis. The client has an exacerbation of
symptoms and has a history of full recovery. This is classified as relapsing-remitting and is the
most common type. Primary-progressive is a steady worsening of the disease with occasional
minor recovery. Secondary-progressive begins as relapsing-remitting but the disease becomes
worse between exacerbations. Progressive-relapsing is rare, with the disease progressing from
the onset with periods of exacerbation.
C) There are four classifications of multiple sclerosis. The client has an exacerbation of
D) There are four classifications of multiple sclerosis. The client has an exacerbation of
Page Ref: 877
direct and indirect causes of multiple sclerosis.
47
2) A young adult client complains of blurred vision and muscle spasms that come and go over
the past several months. On what information from the client's history should the nurse focus to
help identify this help problem?
A) Family history of Parkinson disease
B) Family history of epilepsy
C) Is an immigrant from Germany
D) Has been depressed
Answer: C
Explanation: A) Multiple sclerosis is primarily a disease of people of northern European
ancestry. The onset of multiple sclerosis is usually between the ages of 20 and 50, with the peak
at age 30. Family history of epilepsy, Parkinson disease, and depression are important items of
the client's history but do not support a diagnosis of MS.
B) Multiple sclerosis is primarily a disease of people of northern European ancestry. The onset of
multiple sclerosis is usually between the ages of 20 and 50, with the peak at age 30. Family
history of epilepsy, Parkinson disease, and depression are important items of the client's history
but do not support a diagnosis of MS.
C) Multiple sclerosis is primarily a disease of people of northern European ancestry. The onset of
multiple sclerosis is usually between the ages of 20 and 50, with the peak at age 30. Family
D) Multiple sclerosis is primarily a disease of people of northern European ancestry. The onset
of multiple sclerosis is usually between the ages of 20 and 50, with the peak at age 30. Family
Page Ref: 877
Learning Outcome: 2. Identify risk factors and prevention methods associated with multiple
sclerosis.
48
3) A client with a history of relapsing-remitting multiple sclerosis is expecting her first child.
What would be indicated for this client?
A) Suggest reproductive counseling, as multiple sclerosis can be genetic.
B) Instruct to expect a period of remission after delivery of the baby.
C) Instruct to expect an exacerbation of symptoms while pregnant.
D) Discuss pain control during labor, as contractions will be severe.
Answer: A
Explanation: A) A definite genetic factor has not been established; however, studies suggest that
genetic factors make some individuals more susceptible to the disorder than others. Reproductive
counseling would be recommended for this client. Pregnancy often brings about remission of
multiple sclerosis, but with a slightly increased relapse rate postpartum. The strength of uterine
contractions in a client with multiple sclerosis is not severe, and because clients often have
lessened sensation, labor may be almost painless.
B) A definite genetic factor has not been established; however, studies suggest that genetic
factors make some individuals more susceptible to the disorder than others. Reproductive
C) A definite genetic factor has not been established; however, studies suggest that genetic
D) A definite genetic factor has not been established; however, studies suggest that genetic
Page Ref: 876-877
across the life span for individuals with multiple sclerosis.
49
4) A client with relapsing-remitting multiple sclerosis tells the nurse that even though the
primary symptoms of exacerbation are leg spasms and blurred vision, the hardest part is trying to
get through the day because of being so tired. Which diagnosis should the nurse identify as a
priority for this client?
A) Fatigue
B) Disturbed Sensory Perception
C) Impaired Physical Mobility
D) Self-Care Deficit
Answer: A
Explanation: A) The client states that the worst part of the disease exacerbation is being tired
even though leg spasms and blurred vision are present. The nurse should identify the diagnosis of
Fatigue as being a priority for this client. The diagnoses of Impaired Physical Mobility because
of the leg spasms and Disturbed Sensory Perception because of the blurred vision are additional
nursing diagnoses applicable for this client, but they are not the priority based on the client's
statement. The client may or may not have a Self-Care Deficit.
B) The client states that the worst part of the disease exacerbation is being tired even though leg
spasms and blurred vision are present. The nurse should identify the diagnosis of Fatigue as
being a priority for this client. The diagnoses of Impaired Physical Mobility because of the leg
spasms and Disturbed Sensory Perception because of the blurred vision are additional nursing
diagnoses applicable for this client, but they are not the priority based on the client's statement.
The client may or may not have a Self-Care Deficit.
C) The client states that the worst part of the disease exacerbation is being tired even though leg
D) The client states that the worst part of the disease exacerbation is being tired even though leg
Page Ref: 883
multiple sclerosis.
50
5) A client admitted with an exacerbation of multiple sclerosis is demonstrating frustration with
eating because hand and arm spasms prevent the proper use of utensils. What should the nurse do
to assist this client?
A) Consult with Occupational Therapy regarding assistive devices for meals.
B) Counsel the client to select finger foods for meals.
C) Plan time to feed the client.
D) Consult with Physical Therapy regarding hand and arm exercises.
Answer: A
Explanation: A) Since the ability to feed oneself is essential to positive self-concept and self-
esteem, the nurse should consult with Occupational Therapy for devices that the client can use to
maintain independence at meal times. The nurse should not counsel the client to select finger
foods for meals, or feed the client. This would not support the client's self-concept and self-
esteem needs. Physical Therapy might be consulted for hand splints, but hand and arm exercises
might not be beneficial for this client.
B) Since the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse
should consult with Occupational Therapy for devices that the client can use to maintain
independence at meal times. The nurse should not counsel the client to select finger foods for
meals, or feed the client. This would not support the client's self-concept and self-esteem needs.
Physical Therapy might be consulted for hand splints, but hand and arm exercises might not be
beneficial for this client.
C) Since the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse
D) Since the ability to feed oneself is essential to positive self-concept and self-esteem, the nurse
Page Ref: 883
Learning Outcome: 6. Plan evidence-based care for an individual with multiple sclerosis and his
or her family in collaboration with other members of the healthcare team.
51
6) A client with multiple sclerosis is observed transferring from the bed to a motorized
wheelchair and applying splints to the lower extremities before entering the bathroom to perform
morning self-care. What could the nurse conclude regarding this observation?
A) The client uses assistive devices to optimize autonomy.
B) The client needs instruction to conduct morning care before applying splints to lower
extremities.
C) The client is dependent upon assistive devices.
D) The client is reliant upon assistive devices for independent.
Answer: A
Explanation: A) The nurse observed the client independently transfer from the bed to a
motorized wheelchair, apply splints, and enter the bathroom to perform morning self-care. This
is evidence that the client uses assistive devices to optimize autonomy. The statement "Client is
reliant upon assistive devices for independence" indicates that the client is not autonomous. The
statement "Client is dependent upon assistive devices" also indicates the client is not
autonomous. The statement "Client needs instruction to conduct morning care before applying
splints to lower extremities" does not take into consideration the client's preference, which might
be to apply the splints before doing self-care.
B) The nurse observed the client independently transfer from the bed to a motorized wheelchair,
apply splints, and enter the bathroom to perform morning self-care. This is evidence that the
client uses assistive devices to optimize autonomy. The statement "Client is reliant upon assistive
devices for independence" indicates that the client is not autonomous. The statement "Client is
dependent upon assistive devices" also indicates the client is not autonomous. The statement
"Client needs instruction to conduct morning care before applying splints to lower extremities"
does not take into consideration the client's preference, which might be to apply the splints
before doing self-care.
C) The nurse observed the client independently transfer from the bed to a motorized wheelchair,
D) The nurse observed the client independently transfer from the bed to a motorized wheelchair,
Page Ref: 883
Learning Outcome: 7. Evaluate expected outcomes for an individual with multiple sclerosis.
52
7) A client with multiple sclerosis is prescribed diazepam (Valium). What assessment finding
indicates that the medication is effective for the client?
A) Muscle spasticity is reduced.
B) Blood glucose level is within normal limits.
C) The client states that muscles are weak.
D) Ophthalmologic examination shows no evidence of cataracts.
Answer: A
Explanation: A) Diazepam (Valium) is a muscle relaxant commonly used for clients with
multiple sclerosis. Diazepam (Valium) does not cause muscle weakness. Evidence of medication
effectiveness would be an observed reduction in muscle spasticity. Glucose intolerance would be
assessed if the client were prescribed an adrenal corticosteroid. Cataract development is also a
side effect of adrenal corticosteroids.
B) Diazepam (Valium) is a muscle relaxant commonly used for clients with multiple sclerosis.
Diazepam (Valium) does not cause muscle weakness. Evidence of medication effectiveness
would be an observed reduction in muscle spasticity. Glucose intolerance would be assessed if
the client were prescribed an adrenal corticosteroid. Cataract development is also a side effect of
adrenal corticosteroids.
C) Diazepam (Valium) is a muscle relaxant commonly used for clients with multiple sclerosis.
D) Diazepam (Valium) is a muscle relaxant commonly used for clients with multiple sclerosis.
Page Ref: 881
care of an individual with multiple sclerosis.
53
8) The nurse is planning care for a client with multiple sclerosis. Which intervention would
address the nursing diagnosis of Fatigue?
A) Encourage increased activity.
B) Schedule physical therapy three times a day.
C) Plan activities with sufficient rest periods.
D) Group activities together so care will not be interrupted.
Answer: C
Explanation: A) Interventions to address the client's diagnosis of Fatigue include assessing the
level of fatigue, arranging activities to include rest periods, and assisting the client to set
priorities regarding activities. Activities should not be grouped together. Increased activity will
not help the client with fatigue. Physical therapy three times a day may be too aggressive for this
client.
B) Interventions to address the client's diagnosis of Fatigue include assessing the level of fatigue,
arranging activities to include rest periods, and assisting the client to set priorities regarding
activities. Activities should not be grouped together. Increased activity will not help the client
with fatigue. Physical therapy three times a day may be too aggressive for this client.
C) Interventions to address the client's diagnosis of Fatigue include assessing the level of fatigue,
D) Interventions to address the client's diagnosis of Fatigue include assessing the level of fatigue,
Page Ref: 883
Learning Outcome: 6. Plan evidence-based care for an individual with multiple sclerosis and his
54
9) The nurse is presenting a talk for the monthly Nursing Case Study education group at her
facility. Which client would be a good choice for a case study on multiple sclerosis (MS)?
A) Brazilian with chronic parasitic infestation
B) Italian with colonized methicillin resistant staphylococcus aureus (MRSA)
C) Northern Canadian who has smoked for 25 years
D) African-American man in his 20s with a vitamin D deficiency
Answer: C
Explanation: A) The client with the greatest risk lives the farthest from the equator and smokes.
Smokers are at increased risk of MS. Brazilians and Italians live close to the equator, which
lowers the risk of MS. Chronic parasitic infestation lowers the immune response, which lowers
the risk of MS. African-Americans and men are at lower risk of developing MS. It is theorized
that vitamin D deficiency may increase risk of MS because it is seen less in locales near the
equator.
B) The client with the greatest risk lives the farthest from the equator and smokes. Smokers are
at increased risk of MS. Brazilians and Italians live close to the equator, which lowers the risk of
MS. Chronic parasitic infestation lowers the immune response, which lowers the risk of MS.
African-Americans and men are at lower risk of developing MS. It is theorized that vitamin D
deficiency may increase risk of MS because it is seen less in locales near the equator.
C) The client with the greatest risk lives the farthest from the equator and smokes. Smokers are
D) The client with the greatest risk lives the farthest from the equator and smokes. Smokers are
Page Ref: 877
Learning Outcome: 2. Identify risk factors and prevention methods associated with multiple
sclerosis.
55
10) A 32-year-old client recently diagnosed with multiple sclerosis is a full-time aerobics
exercise instructor at a local fitness center. Which statements contain the correct information to
give the client when answering her specific questions about lifestyle?
A) "Hyperbaric oxygen treatment is recommended prior to vigorous physical exercise."
B) "You will tolerate exercise better in an air-conditioned room."
C) "Acupuncture may benefit some of your symptoms."
D) "Drinking cold water is recommended during exercise."
E) "You will be able to maintain your exercise teaching schedule."
Answer: B, C, D
Explanation: A) Symptoms of MS are exacerbated by increased body temperature. Exercising in
a cold room and drinking cold beverages keep body temperature down. Acupuncture has low risk
and may be beneficial for some symptoms. Hyperbaric oxygen therapy carries more risk than
benefit. It is unlikely that a newly diagnosed client with MS will be able to tolerate a full-time
exercise instructor role.
B) Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room
and drinking cold beverages keep body temperature down. Acupuncture has low risk and may be
beneficial for some symptoms. Hyperbaric oxygen therapy carries more risk than benefit. It is
unlikely that a newly diagnosed client with MS will be able to tolerate a full-time exercise
instructor role.
C) Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room
instructor role.
D) Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room
instructor role.
E) Symptoms of MS are exacerbated by increased body temperature. Exercising in a cold room
instructor role.
Page Ref: 877
across the life span for individuals with multiple sclerosis.
56
11) During an outpatient clinic follow-up appointment, a 46-year-old client with multiple
sclerosis (MS) has lab tests completed. The results show elevated levels of aspartate
aminotransferase (AST), serum glutamic-oxaloacetic transaminase (SGOT), alanine
aminotransferase (ALT), serum glutamic-pyruvic transaminase (SGPT), and alkaline
phosphatase (ALP). What is the priority concern for the nurse??
A) Adverse response to Avonex
B) Adverse response to Aubagio
C) Flare-up due to demyelination
D) Adverse response to bisacodyl
E) Damage from viral infection
Answer: A, B
Explanation: A) AST, SGOT, ALT, SGPT and ALP are liver enzymes that are monitored to
detect adverse response to the medications Avonex and Aubagio. Flare-ups due to demyelination
do not cause liver enzymes to increase. Bisacodyl is a stool softener used for constipation in MS
and does not cause liver enzymes to elevate. Incomplete evidence links viral infection to the risk
of MS. There is no reason to attribute elevated liver enzymes to viral exposure.
B) AST, SGOT, ALT, SGPT and ALP are liver enzymes that are monitored to detect adverse
response to the medications Avonex and Aubagio. Flare-ups due to demyelination do not cause
liver enzymes to increase. Bisacodyl is a stool softener used for constipation in MS and does not
cause liver enzymes to elevate. Incomplete evidence links viral infection to the risk of MS. There
is no reason to attribute elevated liver enzymes to viral exposure.
C) AST, SGOT, ALT, SGPT and ALP are liver enzymes that are monitored to detect adverse
D) AST, SGOT, ALT, SGPT and ALP are liver enzymes that are monitored to detect adverse
E) AST, SGOT, ALT, SGPT and ALP are liver enzymes that are monitored to detect adverse
Page Ref: 880
care of an individual with multiple sclerosis.
57
Exemplar 13.5 Osteoarthritis
1) A client tells the nurse about being diagnosed with osteoarthritis but does not know what that
means. What should the nurse explain to the client about osteoarthritis?
A) Most commonly seen in thin, small-built female clients
B) A result of synovial inflammation
C) Erosion of joint articular cartilage with new bone formation in the joint space
D) A metabolic bone disease
Answer: C
Explanation: A) Osteoarthritis is characterized by progressive erosion of the cartilage within
joints, which is then replaced by new bone in the joint spaces. Metabolic bone diseases include
osteoporosis, osteomalacia, and Paget disease. Obesity is associated with osteoarthritis. Thin
body size is associated with osteoporosis. Osteoarthritis is a non-inflammatory joint disease.
Rheumatoid arthritis is a joint disease that involves synovial inflammation.
B) Osteoarthritis is characterized by progressive erosion of the cartilage within joints, which is
then replaced by new bone in the joint spaces. Metabolic bone diseases include osteoporosis,
osteomalacia, and Paget disease. Obesity is associated with osteoarthritis. Thin body size is
associated with osteoporosis. Osteoarthritis is a non-inflammatory joint disease. Rheumatoid
arthritis is a joint disease that involves synovial inflammation.
C) Osteoarthritis is characterized by progressive erosion of the cartilage within joints, which is
D) Osteoarthritis is characterized by progressive erosion of the cartilage within joints, which is
Page Ref: 886
direct and indirect causes of osteoarthritis.
58
2) A client with osteoarthritis of the knees tells the nurse that no one else in the family has this
disorder. What assessment finding might have increased this client's risk for developing this
disorder?
A) Body mass index 36.5
B) History of esophageal reflux disease
C) Client plays tennis 3 times each week
D) Blood pressure 136/78 mmHg
Answer: A
Explanation: A) Obesity also increases the risk of developing OA, because the added weight
increases stress on weight-bearing joints, causing the joints to wear down more quickly. The
client has a body mass index of 36.5, which is considered obese. Moderate recreational exercise
has been shown to decrease the chance of developing osteoarthritis and the progression of
manifestations when osteoarthritis is present. Esophageal reflux is not associated with the
disorder. Blood pressure is not a known risk factor for the development of osteoarthritis.
B) Obesity also increases the risk of developing OA, because the added weight increases stress
on weight-bearing joints, causing the joints to wear down more quickly. The client has a body
mass index of 36.5, which is considered obese. Moderate recreational exercise has been shown to
decrease the chance of developing osteoarthritis and the progression of manifestations when
osteoarthritis is present. Esophageal reflux is not associated with the disorder. Blood pressure is
not a known risk factor for the development of osteoarthritis.
C) Obesity also increases the risk of developing OA, because the added weight increases stress
D) Obesity also increases the risk of developing OA, because the added weight increases stress
Page Ref: 887
Learning Outcome: 2. Identify risk factors and prevention methods associated with
osteoarthritis.
59
3) An older client with bilateral osteoarthritis of the knees tells the nurse that she knows she
needs to lose weight but exercise will just make her knees ache more. What instruction should
the nurse provide to this client?
A) Discuss knee replacement surgery with the physician.
B) Exercise the muscles so that they will protect the joints.
C) Eat a reduced-calorie diet for several months before attempting exercise.
D) Stretch the muscles, because that is the only form of exercise that improves osteoarthritis.
Answer: B
Explanation: A) Exercise is an important aspect of nursing care for clients with osteoarthritis.
Exercise can increase flexibility, improve blood flow, help the client lose weight, and improve
mood. This is what the nurse should instruct the client. The nurse should not counsel the client to
follow a reduced-calorie eating plan for several months before attempting exercise. The client
may or may not want to have knee replacement surgery. Stretching is just one type of exercise
that will help a client with osteoarthritis. The other components, strengthening and aerobic
exercise, can be obtained through walking, swimming, and isometric, isotonic, and resistive
exercises.
B) Exercise is an important aspect of nursing care for clients with osteoarthritis. Exercise can
increase flexibility, improve blood flow, help the client lose weight, and improve mood. This is
what the nurse should instruct the client. The nurse should not counsel the client to follow a
reduced-calorie eating plan for several months before attempting exercise. The client may or may
not want to have knee replacement surgery. Stretching is just one type of exercise that will help a
client with osteoarthritis. The other components, strengthening and aerobic exercise, can be
obtained through walking, swimming, and isometric, isotonic, and resistive exercises.
C) Exercise is an important aspect of nursing care for clients with osteoarthritis. Exercise can
D) Exercise is an important aspect of nursing care for clients with osteoarthritis. Exercise can
Page Ref: 887
across the life span for individuals with osteoarthritis.
60
4) The nurse is planning care for a client with osteoarthritis. Which diagnosis would have the
highest priority?
A) Fatigue
B) Chronic Pain
C) Ineffective Coping
D) Disturbed Body Image
Answer: B
Explanation: A) When providing care to the client diagnosed with osteoarthritis, priority
diagnoses would include Chronic Pain, Impaired Physical Mobility, and Self-Care Deficit. Of the
diagnoses identified for the client, Chronic Pain would be the priority for the client's
musculoskeletal status. There is not enough information to determine if the client has Fatigue, a
Disturbed Body Image, or Ineffective Coping.
B) When providing care to the client diagnosed with osteoarthritis, priority diagnoses would
include Chronic Pain, Impaired Physical Mobility, and Self-Care Deficit. Of the diagnoses
identified for the client, Chronic Pain would be the priority for the client's musculoskeletal
status. There is not enough information to determine if the client has Fatigue, a Disturbed Body
Image, or Ineffective Coping.
C) When providing care to the client diagnosed with osteoarthritis, priority diagnoses would
D) When providing care to the client diagnosed with osteoarthritis, priority diagnoses would
Page Ref: 891
osteoarthritis.
61
5) The nurse is planning care for a client with osteoarthritis of the hip. Which intervention would
be appropriate for this client?
A) Provide moist heat packs to affected joint 3 times each day.
B) Instruct on the importance of strict bed rest.
C) Provide NSAIDs when pain is severe.
D) Provide opioid pain medication as prescribed.
Answer: A
Explanation: A) Interventions appropriate for a client with osteoarthritis include NSAIDs, moist
heat, active range-of-motion exercises, proper posture and body mechanics, and assistive devices
to safely maintain independence with activities of daily living. Opioid medication is not typically
prescribed for the treatment of osteoarthritis. NSAIDs are more effective if taken before the pain
is severe. The client should be encouraged to be mobile, not on strict bed rest.
B) Interventions appropriate for a client with osteoarthritis include NSAIDs, moist heat, active
range-of-motion exercises, proper posture and body mechanics, and assistive devices to safely
maintain independence with activities of daily living. Opioid medication is not typically
C) Interventions appropriate for a client with osteoarthritis include NSAIDs, moist heat, active
D) Interventions appropriate for a client with osteoarthritis include NSAIDs, moist heat, active
Page Ref: 889
Learning Outcome: 6. Plan evidence-based care for an individual with osteoarthritis and his or
62
6) The nurse is evaluating care provided to a client with osteoarthritis. Which client statement
indicates to the nurse that interventions for osteoarthritis have been successful?
A) "I had to take early retirement and now stay at home all day and rest my legs."
B) "I am sleeping throughout the night and have not missed any work because of knee pain."
C) "I am moving from my two-story house into the first floor of my daughter's home so I won't
have to walk steps anymore."
D) "I changed my work hours so now I work part time and have a nursing assistant who helps me
bathe twice a week at home."
Answer: B
Explanation: A) Expected outcomes for the care of the client with osteoarthritis include
independence with activities of daily living, minimal lifestyle impact because of osteoarthritis,
and controlled pain to allow for rest and sleep. Of the client statements provided, the one that
would indicate the success of the interventions is the one about improved sleep and pain not
interfering with work. The client who changed work hours and has a nursing assistant for bathing
is experiencing a reduction in activities of daily living and a significant impact in lifestyle. The
client who is moving in with a daughter is experiencing significant lifestyle impact. The client
who retired early and stays at home all day and rests also has had a significant impact in lifestyle.
B) Expected outcomes for the care of the client with osteoarthritis include independence with
activities of daily living, minimal lifestyle impact because of osteoarthritis, and controlled pain
to allow for rest and sleep. Of the client statements provided, the one that would indicate the
success of the interventions is the one about improved sleep and pain not interfering with work.
The client who changed work hours and has a nursing assistant for bathing is experiencing a
reduction in activities of daily living and a significant impact in lifestyle. The client who is
moving in with a daughter is experiencing significant lifestyle impact. The client who retired
early and stays at home all day and rests also has had a significant impact in lifestyle.
C) Expected outcomes for the care of the client with osteoarthritis include independence with
D) Expected outcomes for the care of the client with osteoarthritis include independence with
Page Ref: 893
Learning Outcome: 7. Evaluate expected outcomes for an individual with osteoarthritis.
63
7) A client with osteoarthritis tells the nurse about difficulty walking to the bathroom first thing
in the morning. Which nursing action would assist this client?
A) Suggest a family member provide the client with a bedpan.
B) Discuss the option of residing in an assisted-living facility.
C) Consult with Physical Therapy for an assistive walking device such as a walker or cane.
D) Suggest using a bedside commode at home.
Answer: C
Explanation: A) Assistive devices are items used to maintain, increase, or improve function. The
client states difficulty with walking in the morning to the bathroom. The best intervention to help
this client would be to consult with Physical Therapy for an assistive walking device such as a
walker or cane. The use of a bedside commode or bedpan may help with the immediate need to
use the bathroom but the client will still have difficulty ambulating in the morning. The option of
residing in an assisted-living facility might be premature for this client.
B) Assistive devices are items used to maintain, increase, or improve function. The client states
difficulty with walking in the morning to the bathroom. The best intervention to help this client
would be to consult with Physical Therapy for an assistive walking device such as a walker or
cane. The use of a bedside commode or bedpan may help with the immediate need to use the
bathroom but the client will still have difficulty ambulating in the morning. The option of
C) Assistive devices are items used to maintain, increase, or improve function. The client states
D) Assistive devices are items used to maintain, increase, or improve function. The client states
Page Ref: 890
care of an individual with osteoarthritis.
64
8) A client with chronic hip pain is diagnosed with osteoarthritis. What should the nurse instruct
this client about home safety?
A) Walk up and down the steps at home as much as possible.
B) Rest in a recliner.
C) Place scatter rugs in high-traffic areas.
D) Install grab bars in the bathroom near the commode and in the shower.
Answer: D
Explanation: A) The client should be encouraged to install grab bars in the bathroom near the
commode and in the shower. The client should be instructed not to overuse the affected joints
with excessive stair climbing. Scatter rugs are a hazard to mobility and should be avoided. The
client should be instructed to sit in a straight-back chair, avoid slumping, and avoid the use of a
recliner.
B) The client should be encouraged to install grab bars in the bathroom near the commode and in
the shower. The client should be instructed not to overuse the affected joints with excessive stair
climbing. Scatter rugs are a hazard to mobility and should be avoided. The client should be
instructed to sit in a straight-back chair, avoid slumping, and avoid the use of a recliner.
C) The client should be encouraged to install grab bars in the bathroom near the commode and in
D) The client should be encouraged to install grab bars in the bathroom near the commode and in
Page Ref: 890
65
9) A 48-year-old client seeking treatment for severe knee pain has worked in a factory for 30
years in a position requiring repetitive lifting and carrying of 20-40-pound boxes. The nurse
anticipates which recommendation from the multidisciplinary team?
A) Joint replacement surgery
B) Pharmacologic therapy
C) Refer for Disability application.
D) Intermittent use of a cane
Answer: B
Explanation: A) Of these options, pharmacologic therapy would be the most likely intervention.
Acetaminophen, non-steroidal anti-inflammatory, and joint injections are all possible options.
Joint replacement is delayed as long as possible due to the artificial joint often requiring
replacement within 15-20 years. There is not enough information to determine whether applying
for Disability is appropriate at this time. A cane is not indicated at this time.
B) Of these options, pharmacologic therapy would be the most likely intervention.
C) Of these options, pharmacologic therapy would be the most likely intervention.
D) Of these options, pharmacologic therapy would be the most likely intervention.
Page Ref: 888-889
care of an individual with osteoarthritis.
66
10) Lab results are back on a client who has limiting joint pain. Synovial fluid analysis shows no
uric acid crystals, bacteria, or blood. The client asks what conditions are possible cause(s) of this
pain. What is the nurse's response?
A) Osteoarthritis
B) Rheumatoid arthritis
C) Septic arthritis
D) Gout
E) Trauma
Answer: A, B
Explanation: A) There are no specific joint fluid tests for osteoarthritis, making this a possible
diagnosis. There is no report of any tests for rheumatoid arthritis, making this a possible
diagnosis. Gout is caused by the collection of uric acid crystals in the joint. The absence of uric
acid crystals in the synovial fluid (joint fluid) makes gout unlikely. Septic arthritis is caused by
infection. The absence of bacteria makes sepsis unlikely. The absence of blood makes trauma
unlikely.
B) There are no specific joint fluid tests for osteoarthritis, making this a possible diagnosis.
There is no report of any tests for rheumatoid arthritis, making this a possible diagnosis. Gout is
caused by the collection of uric acid crystals in the joint. The absence of uric acid crystals in the
synovial fluid (joint fluid) makes gout unlikely. Septic arthritis is caused by infection. The
absence of bacteria makes sepsis unlikely. The absence of blood makes trauma unlikely.
C) There are no specific joint fluid tests for osteoarthritis, making this a possible diagnosis.
D) There are no specific joint fluid tests for osteoarthritis, making this a possible diagnosis.
E) There are no specific joint fluid tests for osteoarthritis, making this a possible diagnosis.
Page Ref: 888
67
11) A client with osteoarthritis of the knees and hips returns for a 3-month follow-up with her
provider. The nurse calculates that the client's BMI is now 22. She reports starting a water
aerobics and step aerobics program three times per week. She is using hot packs for edema for 20
minutes and cold packs for pain for 40 minutes daily. After evaluating the client's actions, the
nurse plans which follow-up interventions?
A) Reinforce the correct use of hot packs.
B) Educate on low-impact exercise modes.
C) Explain the risk of injury using cold packs.
D) Counsel on continued weight loss.
E) Congratulate on starting water aerobics.
Answer: B, C, E
Explanation: A) Congratulate the client on starting water exercise. Also congratulate on weight
loss. A BMI of 22 is ideal. Do not encourage continued weight loss. Educate the client that using
cold packs for over 30 minutes may cause skin injury. Reinforce that hot packs are used to
decrease pain and ice packs are used for edema (swelling). Educate on the negative effect that
high-impact step aerobics may have on the joints.
B) Congratulate the client on starting water exercise. Also congratulate on weight loss. A BMI of
22 is ideal. Do not encourage continued weight loss. Educate the client that using cold packs for
over 30 minutes may cause skin injury. Reinforce that hot packs are used to decrease pain and
ice packs are used for edema (swelling). Educate on the negative effect that high-impact step
aerobics may have on the joints.
C) Congratulate the client on starting water exercise. Also congratulate on weight loss. A BMI of
D) Congratulate the client on starting water exercise. Also congratulate on weight loss. A BMI of
E) Congratulate the client on starting water exercise. Also congratulate on weight loss. A BMI of
Page Ref: 891
Learning Outcome: 7. Evaluate expected outcomes for an individual with osteoarthritis.
68
Exemplar 13.6 Parkinson Disease
1) A client complains of a right-hand tremor, increasing weakness, and muscles feeling tight.
The nurse notes the client has poor voice volume and facial muscles do not move easily. What do
these assessment findings suggest to the nurse?
A) Parkinson disease
B) Spinal cord injury
C) Cerebral vascular accident
D) Multiple sclerosis
Answer: A
Explanation: A) Manifestations of Parkinson disease include unintentional tremor, slowed
movements, low amplitude of speech, expressionless face, and muscle rigidity. The client is
complaining of or exhibiting all these symptoms, indicating Parkinson disease. These symptoms
are not manifestations of multiple sclerosis, spinal cord injury, or a cerebral vascular accident.
B) Manifestations of Parkinson disease include unintentional tremor, slowed movements, low
amplitude of speech, expressionless face, and muscle rigidity. The client is complaining of or
exhibiting all these symptoms, indicating Parkinson disease. These symptoms are not
manifestations of multiple sclerosis, spinal cord injury, or a cerebral vascular accident.
C) Manifestations of Parkinson disease include unintentional tremor, slowed movements, low
D) Manifestations of Parkinson disease include unintentional tremor, slowed movements, low
Page Ref: 896
direct and indirect causes of Parkinson disease.
69
2) A middle-aged female client tells the nurse that she is noticing a slight tremor of her left hand
when at rest. The client is concerned that she has Parkinson disease, as her mother had the illness
and passed away because of respiratory failure. What should the nurse respond to this client?
A) "Having a first-degree relative with the illness can increase your chance of developing it as
well."
B) "You should not worry, as it has a higher prevalence in males."
C) "It is unlikely that you have the same illness as your mother."
D) "You probably do not have it, as your mother was probably exposed to a toxin that caused the
disease."
Answer: A
Explanation: A) In a few individuals, PD is inherited; approximately 15% to 25% of individuals
with PD have a relative with PD. The nurse should not tell the client that it is unlikely she has the
same illness as her mother. Exposure to toxins is one theory for the development of the illness;
however, the nurse has no way of knowing if the client's mother was exposed to toxins or if that
was the cause for the disease. Parkinson disease occurs equally in males and females. Two
percent of adults over age 65 have the diagnosis.
B) In a few individuals, PD is inherited; approximately 15% to 25% of individuals with PD have
a relative with PD. The nurse should not tell the client that it is unlikely she has the same illness
as her mother. Exposure to toxins is one theory for the development of the illness; however, the
nurse has no way of knowing if the client's mother was exposed to toxins or if that was the cause
for the disease. Parkinson disease occurs equally in males and females. Two percent of adults
over age 65 have the diagnosis.
C) In a few individuals, PD is inherited; approximately 15% to 25% of individuals with PD have
D) In a few individuals, PD is inherited; approximately 15% to 25% of individuals with PD have
Page Ref: 896
Learning Outcome: 2. Identify risk factors and prevention methods associated with Parkinson
disease.
70
3) A client with Parkinson disease tells the nurse that it is 1950 and he is late for work. What
action should the nurse take at this time?
A) Orient the client, provide a calendar, and place a clock in the room.
B) Ask the client what life is like in 1950.
C) Medicate for confusion.
D) Apply restraints so the client will not attempt to get out of bed to go to work.
Answer: A
Explanation: A) Clients with Parkinson disease may demonstrate confusion and disorientation.
This is what the client is demonstrating. The nurse should orient the client, provide a calendar,
and place a clock in the room to assist with ongoing orientation. The nurse should not medicate
the client for confusion or apply restraints. The nurse should not feed into the confusion by
asking what life is like in 1950.
B) Clients with Parkinson disease may demonstrate confusion and disorientation. This is what
the client is demonstrating. The nurse should orient the client, provide a calendar, and place a
clock in the room to assist with ongoing orientation. The nurse should not medicate the client for
confusion or apply restraints. The nurse should not feed into the confusion by asking what life is
like in 1950.
C) Clients with Parkinson disease may demonstrate confusion and disorientation. This is what
like in 1950.
D) Clients with Parkinson disease may demonstrate confusion and disorientation. This is what
like in 1950.
Page Ref: 902
across the life span for individuals with Parkinson disease.
71
4) A client with Parkinson disease ambulates with a shuffling gait and leans slightly forward.
When seated, the client conducts a conversation, reads, and is able to self-feed without
assistance. Which diagnosis is a priority for this client?
A) Ineffective Coping
B) Impaired Physical Mobility
C) Imbalanced Nutrition: More than Body Requirements
D) Anxiety
Answer: B
Explanation: A) The client demonstrates a shuffled gait with forward leaning when ambulating.
When seated, the client is able to converse, read, and self-feed. Of the diagnoses listed, the one
with the highest priority would be Impaired Physical Mobility. Imbalanced Nutrition would not
be a priority, as the client can feed himself. There is no evidence to support the diagnoses of
Ineffective Coping and Anxiety at this time.
B) The client demonstrates a shuffled gait with forward leaning when ambulating. When seated,
the client is able to converse, read, and self-feed. Of the diagnoses listed, the one with the highest
priority would be Impaired Physical Mobility. Imbalanced Nutrition would not be a priority, as
the client can feed himself. There is no evidence to support the diagnoses of Ineffective Coping
and Anxiety at this time.
C) The client demonstrates a shuffled gait with forward leaning when ambulating. When seated,
D) The client demonstrates a shuffled gait with forward leaning when ambulating. When seated,
Page Ref: 903
Parkinson disease.
72
5) The nurse, planning care for a client with Parkinson disease, identifies which intervention as
supporting mobility while providing the spouse with an activity that is beneficial for the client?
A) Suggest the spouse use a blender to make foods easier for the client to swallow.
B) Review the medication administration schedule with the spouse.
C) Instruct the spouse to ambulate the client at least four times a day.
D) Instruct the spouse on proper turning and repositioning techniques.
Answer: C
Explanation: A) Since exercise fosters independence and self-esteem, the intervention that
would support physical mobility while providing the spouse with an activity beneficial for the
client would be to instruct the spouse to ambulate the client at least four times a day. Instructing
on turning and repositioning techniques would not support physical mobility. Blending foods to
aid with swallowing will not support physical mobility. Reviewing the medication administration
schedule will not support physical mobility.
B) Since exercise fosters independence and self-esteem, the intervention that would support
physical mobility while providing the spouse with an activity beneficial for the client would be
to instruct the spouse to ambulate the client at least four times a day. Instructing on turning and
repositioning techniques would not support physical mobility. Blending foods to aid with
swallowing will not support physical mobility. Reviewing the medication administration
C) Since exercise fosters independence and self-esteem, the intervention that would support
D) Since exercise fosters independence and self-esteem, the intervention that would support
Page Ref: 904
Learning Outcome: 6. Plan evidence-based care for an individual with Parkinson disease and his
73
6) The nurse is evaluating the care of a client with Parkinson disease. Which finding indicates an
improvement in nutritional status?
A) The client was observed providing morning self-care and dressing.
B) The client coughs frequently when drinking fluids.
C) The client was able to feed self and had no weight change in 1 week.
D) The client had a 4-pound weight loss in 1 week.
Answer: C
Explanation: A) Evidence that interventions to improve the client's nutritional status were
effective would be the client's self-feeding with no change in weight. Observing the client with
morning self-care and dressing does not evaluate interventions to address nutritional status. If the
client coughs frequently when drinking fluids, it could indicate that interventions to address
nutritional status have not been effective. The client's losing 4 pounds in 1 week would not
support an improvement in nutritional status.
B) Evidence that interventions to improve the client's nutritional status were effective would be
the client's self-feeding with no change in weight. Observing the client with morning self-care
and dressing does not evaluate interventions to address nutritional status. If the client coughs
frequently when drinking fluids, it could indicate that interventions to address nutritional status
have not been effective. The client's losing 4 pounds in 1 week would not support an
improvement in nutritional status.
C) Evidence that interventions to improve the client's nutritional status were effective would be
D) Evidence that interventions to improve the client's nutritional status were effective would be
Page Ref: 904
Learning Outcome: 7. Evaluate expected outcomes for an individual with Parkinson disease.
74
7) A spouse expresses frustration when trying to communicate with a client with Parkinson
disease. What can the nurse do to facilitate communication between the client and spouse?
A) Recommend that the client and spouse learn sign language.
B) Suggest the spouse obtain a hearing aid.
C) Consult with Speech Therapy for exercises to aid with speech and language.
D) Suggest communicating by writing.
Answer: C
Explanation: A) The spouse is frustrated with the client's impaired verbal communication. The
best intervention would be to consult with Speech Therapy for exercises to aid with speech and
language. The spouse does not need a hearing aid. The spouse and client do not need to learn
sign language in order to communicate. The client may or may not be able to write, because of
hand tremors.
B) The spouse is frustrated with the client's impaired verbal communication. The best
intervention would be to consult with Speech Therapy for exercises to aid with speech and
hand tremors.
C) The spouse is frustrated with the client's impaired verbal communication. The best
hand tremors.
D) The spouse is frustrated with the client's impaired verbal communication. The best
hand tremors.
Page Ref: 904-905
care of an individual with Parkinson disease.
75
8) The nurse instructs a client with Parkinson disease about carbidopa-levodopa (Sinemet).
Which client statement indicates that teaching has been effective?
A) "I will take the medication with my meals."
B) "I will sit up for several minutes to gain my balance before going from lying down to standing
up."
C) "This medication will not affect my blood pressure medications."
D) "This medication will cure my Parkinson disease in time."
Answer: B
Explanation: A) Carbidopa-levodopa is a medication that replaces the dopamine that is lacking
in clients with Parkinson disease. This medication is likely to cause orthostatic hypotension, so
the client must take care when changing positions from lying to standing. The medication should
be taken 1 hour before or 2 hours after meals to promote absorption of the medication. There is
no medication known to cure Parkinson disease. Care must be taken if the client is also taking
medications to lower the blood pressure because a cumulative effect may occur, leading to
hypotension and increased risk for falling.
B) Carbidopa-levodopa is a medication that replaces the dopamine that is lacking in clients with
Parkinson disease. This medication is likely to cause orthostatic hypotension, so the client must
take care when changing positions from lying to standing. The medication should be taken 1
hour before or 2 hours after meals to promote absorption of the medication. There is no
medication known to cure Parkinson disease. Care must be taken if the client is also taking
C) Carbidopa-levodopa is a medication that replaces the dopamine that is lacking in clients with
D) Carbidopa-levodopa is a medication that replaces the dopamine that is lacking in clients with
Page Ref: 899
Learning Outcome: 7. Evaluate expected outcomes for an individual with Parkinson disease.
76
9) The nurse completes teaching for a 22-year-old client diagnosed with Parkinson disease (PD).
Which client statement indicates teaching has been effective?
A) "I could have prevented PD with diet and exercise."
B) "I probably have a genetic mutation that caused PD."
C) "My brain has too much of a chemical called dopamine."
D) "Most people get PD when they are my age."
Answer: B
Explanation: A) Early-onset Parkinson disease is likely due to a genetic mutation. Increasing
age is a risk factor for PD; age 22 is uncommon. In PD there is a deficit of available dopamine.
Although a healthy diet avoiding pesticides is recommended, it is not a proven causative agent.
B) Early-onset Parkinson disease is likely due to a genetic mutation. Increasing age is a risk
factor for PD; age 22 is uncommon. In PD there is a deficit of available dopamine. Although a
healthy diet avoiding pesticides is recommended, it is not a proven causative agent.
C) Early-onset Parkinson disease is likely due to a genetic mutation. Increasing age is a risk
D) Early-onset Parkinson disease is likely due to a genetic mutation. Increasing age is a risk
Page Ref: 896
direct and indirect causes of Parkinson disease.
77
10) A client is being evaluated for Parkinson disease (PD). Which findings on the Unified
Parkinson Disease Rating Scale (UPDRS) would suggest a positive finding for PD?
A) Diarrhea
B) Dystonia
C) Retropulsion
D) Hyperphonia
E) Festination
Answer: B, C, E
Explanation: A) The Unified Parkinson Disease Rating Scale (UPDRS) rates the client in 42
different areas of function. Positive findings for PD are retropulsion (the tendency to fall
backward), festination (rapid walking as if trying to run) and dystonia (twisting and repetitive
movements). Diarrhea and hyperphonia (loud voice) are not symptoms of PD. Constipation and
hypophonia (soft voice) are symptoms of PD.
B) The Unified Parkinson Disease Rating Scale (UPDRS) rates the client in 42 different areas of
function. Positive findings for PD are retropulsion (the tendency to fall backward), festination
(rapid walking as if trying to run) and dystonia (twisting and repetitive movements). Diarrhea
and hyperphonia (loud voice) are not symptoms of PD. Constipation and hypophonia (soft voice)
are symptoms of PD.
C) The Unified Parkinson Disease Rating Scale (UPDRS) rates the client in 42 different areas of
are symptoms of PD.
D) The Unified Parkinson Disease Rating Scale (UPDRS) rates the client in 42 different areas of
are symptoms of PD.
E) The Unified Parkinson Disease Rating Scale (UPDRS) rates the client in 42 different areas of
are symptoms of PD.
Page Ref: 903
across the life span for individuals with Parkinson disease.
78
11) The interdisciplinary treatment team proposes interventions to improve and maintain
physical function for a 65-year-old client with Parkinson disease. Which interventions are
supported by research?
A) Low-intensity treadmill training
B) Walking barefoot indoors
C) Use of resistance bands
D) Active and passive range of motion
E) High-intensity treadmill training
Answer: A, C, D, E
Explanation: A) Research studies have shown improvements on the 6-minute walk test of
individuals with Parkinson disease after participation in low-intensity and high-intensity
treadmill training, strength training, and range of motion. Use of shoes with non-slip soles is
advised.
B) Research studies have shown improvements on the 6-minute walk test of individuals with
Parkinson disease after participation in low-intensity and high-intensity treadmill training,
strength training, and range of motion. Use of shoes with non-slip soles is advised.
C) Research studies have shown improvements on the 6-minute walk test of individuals with
D) Research studies have shown improvements on the 6-minute walk test of individuals with
E) Research studies have shown improvements on the 6-minute walk test of individuals with
Page Ref: 904
Client Need Sub: Management of Care
Nursing Process: Communication and Documentation
care of an individual with Parkinson disease.
79
Exemplar 13.7 Spinal Cord Injury
1) A client admitted 3 days prior with an injury to the thoracic area of the spinal cord tells the
nurse, "I'm getting worse. It's harder to breathe." What should the nurse suspect is occurring with
this client?
A) The client has atelectasis.
B) The extent of injury cannot yet be determined.
C) The client is improving.
D) The client is developing pneumonia.
Answer: B
Explanation: A) With a spinal cord injury, there is an area of ischemia and edema. Because
edema extends from the level of injury for two cord segments above and below the affected
level, the extent of injury cannot be determined for up to 1 week. The client's complaint of it
being harder to breathe could be evidence that extent of injury is becoming more obvious but
will not be totally determined for a few more days. The client's complaint of it being harder to
breathe may or may not indicate pneumonia or atelectasis. The complaint is not evidence that the
client is improving.
B) With a spinal cord injury, there is an area of ischemia and edema. Because edema extends
from the level of injury for two cord segments above and below the affected level, the extent of
injury cannot be determined for up to 1 week. The client's complaint of it being harder to breathe
could be evidence that extent of injury is becoming more obvious but will not be totally
determined for a few more days. The client's complaint of it being harder to breathe may or may
not indicate pneumonia or atelectasis. The complaint is not evidence that the client is improving.
C) With a spinal cord injury, there is an area of ischemia and edema. Because edema extends
D) With a spinal cord injury, there is an area of ischemia and edema. Because edema extends
Page Ref: 909-910
direct and indirect causes of spinal cord injury.
80
2) An adolescent is brought into the Emergency Department with injuries sustained from a motor
vehicle crash. What should the nurse ensure while caring for this client?
A) An adequate urine output
B) Stable blood pressure
C) Stabilization of the neck and spinal cord
D) Intravenous access line
Answer: C
Explanation: A) The danger of death from a spinal cord injury is greatest when there is damage
to or transection of the upper cervical region. All people who have sustained trauma to the spine
should be treated as though they have a spinal cord injury by stabilizing the neck and spinal cord.
Assessment of urine output can be delayed. Assessing blood pressure is an intervention for all
clients brought into the Emergency Department. An intravenous access line is necessary, but the
stabilization of the neck and spinal cord is of first priority.
B) The danger of death from a spinal cord injury is greatest when there is damage to or
transection of the upper cervical region. All people who have sustained trauma to the spine
C) The danger of death from a spinal cord injury is greatest when there is damage to or
D) The danger of death from a spinal cord injury is greatest when there is damage to or
Page Ref: 913
Learning Outcome: 2. Identify risk factors and prevention methods associated with spinal cord
injury.
81
3) A school nurse is treating a school-age child who has fallen down a flight of stairs. The child
is breathing but unconsciousness. After calling the ambulance, what should the nurse do?
A) Open the airway using the head tilt maneuver.
B) Try to rouse the client by gently shaking the shoulders.
C) Protect the client's neck and head from any movement.
D) Place the client on the side to prevent aspiration.
Answer: C
Explanation: A) Guidelines for emergency care are avoiding flexing, extending, or rotating the
neck; immobilization of the neck; securing the head; maintaining the client in the supine
position; and transferring from the stretcher with backboard in place to the hospital bed. This
client is unconscious, and the nurse must protect the neck from any (or any further) damage. If
the client vomits, the nurse should utilize the log-roll technique to turn the client while keeping
the head, neck, and spine in alignment. The client is breathing; however, if a change in
respirations were to occur, the airway should be opened using the jaw thrust maneuver. Rousing
the client by shaking could cause damage to the spinal cord.
B) Guidelines for emergency care are avoiding flexing, extending, or rotating the neck;
immobilization of the neck; securing the head; maintaining the client in the supine position; and
transferring from the stretcher with backboard in place to the hospital bed. This client is
unconscious, and the nurse must protect the neck from any (or any further) damage. If the client
vomits, the nurse should utilize the log-roll technique to turn the client while keeping the head,
neck, and spine in alignment. The client is breathing; however, if a change in respirations were to
occur, the airway should be opened using the jaw thrust maneuver. Rousing the client by shaking
could cause damage to the spinal cord.
C) Guidelines for emergency care are avoiding flexing, extending, or rotating the neck;
D) Guidelines for emergency care are avoiding flexing, extending, or rotating the neck;
Page Ref: 913
across the life span for individuals with a spinal cord injury.
82
4) A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular
respiratory pattern with the rate of 8-10 breaths per minute. What would be a priority nursing
diagnosis for the client at this time?
A) Impaired Physical Mobility
B) Autonomic Dysreflexia
C) Ineffective Breathing Pattern
D) Impaired Gas Exchange
Answer: C
Explanation: A) Since the client sustained the neck injury 2 days prior, the full extent of the
injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20
per minute. Since the client is breathing irregularly at a rate of 8-10 breaths per minute, the client
may need assisted ventilation or a tracheostomy. The nursing diagnosis priority for this client
would be Ineffective Breathing Pattern. An Impaired Gas Exchange could occur because of the
Ineffective Breathing Pattern and would be the second in priority for this client. Impaired
Physical Mobility and Autonomic Dysreflexia could be addressed at a later time.
B) Since the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet
be determined. The client's rate of respirations should be between 12 and 20 per minute. Since
the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need
assisted ventilation or a tracheostomy. The nursing diagnosis priority for this client would be
Ineffective Breathing Pattern. An Impaired Gas Exchange could occur because of the Ineffective
Breathing Pattern and would be the second in priority for this client. Impaired Physical Mobility
and Autonomic Dysreflexia could be addressed at a later time.
C) Since the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet
D) Since the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet
Page Ref: 916
spinal cord injury.
83
5) The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which
interventions would be appropriate for the nursing diagnosis of Alteration in Perfusion?
A) Discuss future care needs when discharged.
B) Increase fluids to 3,000 mL per day.
C) Turn and reposition every 2 hours.
D) Assess for a full bladder.
E) Assess blood pressure every 2-3 minutes.
Answer: D, E
Explanation: A) An alteration in perfusion can be caused by autonomic dysreflexia, which is an
emergency that requires immediate assessment and intervention. The nurse should continue to
assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed
and removing TED hose to encourage the pooling of blood in the extremities and decrease the
blood pressure. Once the blood pressure has stabilized or decreased, the nurse can then assess for
the stimuli which caused the episode, such as a full bladder. Discussing future care needs when
discharged is not a priority at this time, or an intervention for Alteration in Perfusion. Turning
the client every 2 hours is not a priority at this time, or an intervention for Alteration in
Perfusion.
B) An alteration in perfusion can be caused by autonomic dysreflexia, which is an emergency
that requires immediate assessment and intervention. The nurse should continue to assess the
client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and
removing TED hose to encourage the pooling of blood in the extremities and decrease the blood
pressure. Once the blood pressure has stabilized or decreased, the nurse can then assess for the
stimuli which caused the episode, such as a full bladder. Discussing future care needs when
Perfusion.
C) An alteration in perfusion can be caused by autonomic dysreflexia, which is an emergency
Perfusion.
D) An alteration in perfusion can be caused by autonomic dysreflexia, which is an emergency
Perfusion.
84
E) An alteration in perfusion can be caused by autonomic dysreflexia, which is an emergency
Perfusion.
Page Ref: 911
Learning Outcome: 6. Plan evidence-based care for an individual with a spinal cord injury and
his or her family in collaboration with other members of the healthcare team.
85
6) The nurse is evaluating the effectiveness of interventions to address a client's bowel and
bladder dysfunction as a result of a spinal cord injury. What would indicate that the interventions
are successful?
A) The client had two episodes of impacted stool over the last week.
B) The client is improving in ability to perform self-urinary catheterization.
C) The client is limiting fluids to reduce need to void.
D) The client has an indwelling urinary catheter and is provided with stool softeners every
morning.
Answer: B
Explanation: A) An ideal outcome for the client with bowel and bladder dysfunction as a result
of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination
habits. If the client's ability to perform self-urinary catheterization is improving, the interventions
can be considered successful. The client with an indwelling urinary catheter receiving stool
softeners every morning is not progressing toward bowel and bladder elimination habits. The
client who had two episodes of impacted stool over the last week is not progressing in bowel
elimination habits. The client who is limiting fluids to reduce the need to void is possibly
hindering his health in order to avoid having to perform self-urinary catheterization.
B) An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal
cord injury would be for the client to attain appropriate bowel and bladder elimination habits. If
the client's ability to perform self-urinary catheterization is improving, the interventions can be
considered successful. The client with an indwelling urinary catheter receiving stool softeners
every morning is not progressing toward bowel and bladder elimination habits. The client who
had two episodes of impacted stool over the last week is not progressing in bowel elimination
habits. The client who is limiting fluids to reduce the need to void is possibly hindering his
health in order to avoid having to perform self-urinary catheterization.
C) An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal
D) An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal
Page Ref: 912
Learning Outcome: 7. Evaluate expected outcomes for an individual with a spinal cord injury.
86
7) The nurse in the Emergency Department is preparing to administer methylprednisolone to a
client with a spinal cord injury. What effect will this medication have on the client?
A) Cause an increase in blood glucose level
B) Improve the level of consciousness
C) Prevent cord damage from ischemia and edema
D) Improve the ability to be adequately ventilated
Answer: C
Explanation: A) High-dose steroid protocol using methylprednisolone must be implemented
within 8 hours of the injury to improve neurologic recovery. Clinical research indicates that the
use of this adrenocorticosteroid is effective in preventing secondary spinal cord damage from
edema and ischemia. This medication may cause hyperglycemia if the client also has a diagnosis
of diabetes. This medication is not provided to improve respirations or improve the level of
consciousness.
B) High-dose steroid protocol using methylprednisolone must be implemented within 8 hours of
the injury to improve neurologic recovery. Clinical research indicates that the use of this
adrenocorticosteroid is effective in preventing secondary spinal cord damage from edema and
ischemia. This medication may cause hyperglycemia if the client also has a diagnosis of diabetes.
This medication is not provided to improve respirations or improve the level of consciousness.
C) High-dose steroid protocol using methylprednisolone must be implemented within 8 hours of
D) High-dose steroid protocol using methylprednisolone must be implemented within 8 hours of
Page Ref: 914
care of an individual with a spinal cord injury.
87
8) The nurse is evaluating the success of a bowel retraining program with a client recovering
from a lower motor neuron spinal cord injury. Which observations indicate that this teaching has
been successful?
A) One episode of bladder incontinence in 8 hours
B) Performs self-urinary catheterization every 4 hours while awake.
C) Transfers to use bedside commode after breakfast to evacuate bowels.
D) Two episodes of impacted stool in 1 week
E) Maintains a high-fluid, high-fiber diet.
Answer: B, C, E
Explanation: A) Evidence that a bowel and bladder retraining program for a client with a spinal
cord injury has been successful includes performing self-urinary catheterization every 4 hours
while awake, transferring to the bedside commode to evacuate bowels after breakfast, and
maintaining a high-fluid and high-fiber diet to prevent constipation. Evidence that this training
has not been successful includes an episode of bladder incontinence and the need to impacted
stool removed twice in 1 week.
B) Evidence that a bowel and bladder retraining program for a client with a spinal cord injury
has been successful includes performing self-urinary catheterization every 4 hours while awake,
transferring to the bedside commode to evacuate bowels after breakfast, and maintaining a high-
fluid and high-fiber diet to prevent constipation. Evidence that this training has not been
successful includes an episode of bladder incontinence and the need to impacted stool removed
twice in 1 week.
C) Evidence that a bowel and bladder retraining program for a client with a spinal cord injury
twice in 1 week.
D) Evidence that a bowel and bladder retraining program for a client with a spinal cord injury
twice in 1 week.
E) Evidence that a bowel and bladder retraining program for a client with a spinal cord injury has
been successful includes performing self-urinary catheterization every 4 hours while awake,
twice in 1 week.
Page Ref: 916
Learning Outcome: 7. Evaluate expected outcomes for an individual with a spinal cord injury.
88
9) A client who sustained a gunshot wound has symptoms below the level of T-12 of ipsilateral
motor paralysis, loss of proprioception and vibratory sense, and contralateral loss of pain and
temperature sensation. Which assumptions are correct?
A) American Spinal Injury Association Impairment Scale score is A.
B) The spinal cord injury is incomplete.
C) These findings are consistent with Brown-Sequard syndrome.
D) Hemisection of the spinal cord is likely.
E) Some recovery of sensory function is higher.
Answer: B, C, D, E
Explanation: A) Hemisection of the spinal cord, usually caused by a penetrating trauma
(gunshot, knife), causes sensory and motor deficits on opposite sides of the body because the
spinal cord injury is incomplete. These findings are consistent with Brown-Sequard syndrome,
which has the best prognosis of all the incomplete spinal cord syndromes. American Spinal
Injury Association (ASIA) Impairment Scale (AIS) score of A indicates a complete spinal cord
injury where no sensory or motor function is preserved in the sacral segments S4-S5.
B) Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife),
causes sensory and motor deficits on opposite sides of the body because the spinal cord injury is
incomplete. These findings are consistent with Brown-Sequard syndrome, which has the best
prognosis of all the incomplete spinal cord syndromes. American Spinal Injury Association
(ASIA) Impairment Scale (AIS) score of A indicates a complete spinal cord injury where no
sensory or motor function is preserved in the sacral segments S4-S5.
C) Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife),
D) Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife),
E) Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife),
Page Ref: 910
direct and indirect causes of spinal cord injury.
89
10) The nurse is presenting a talk on spinal cord injury for a community health fair. Which
statement indicates that the attendees understand the risk factors and prevention methods
associated with spinal cord injury?
A) "There isn't much I can do to prevent a head injury when another vehicle hits my car."
B) "As long as my grandson wears a helmet, he will be safe on his motorcycle."
C) "I'm going to spend extra time discussing this talkmy Boy Scout troop because of their higher
risk for spinal cord injury."
D) "Due to their high risk, I'd like you to present this talk to the Native American population."
Answer: C
Explanation: A) The highest-risk population for spinal cord injuries is males between 16 and 30
years old. Riding motorcycles increases spinal cord injuries. Native Americans are the ethic
group with the lowest risk of spinal cord injury. Using a seat belt is a major preventive action for
an individual involved in a motor vehicle accident.
B) The highest-risk population for spinal cord injuries is males between 16 and 30 years old.
Riding motorcycles increases spinal cord injuries. Native Americans are the ethic group with the
lowest risk of spinal cord injury. Using a seat belt is a major preventive action for an individual
involved in a motor vehicle accident.
C) The highest-risk population for spinal cord injuries is males between 16 and 30 years old.
D) The highest-risk population for spinal cord injuries is males between 16 and 30 years old.
Page Ref: 908
Learning Outcome: 2. Identify risk factors and prevention methods associated with spinal cord
injury.
90
11) You assess a young adult client that sustained a swimming accident, resulting in tetraplegia.
The client makes eye contact with you and verbalizes, "I'm going to beat this and walk out of
here." Which nursing diagnosis is best supported by this data?
A) Risk for Post-Trauma Syndrome
B) Impaired Physical Mobility
C) Self-Care Deficit
D) Noncompliance
Answer: A
Explanation: A) The client's statement is unrealistic and is evidence of Risk for Post-Trauma
Syndrome. Although the client with tetraplegia does have Impaired Physical Mobility and Self-
Care Deficit, this statement is not evidence of those nursing diagnoses. There is no indication of
Noncompliance.
B) The client's statement is unrealistic and is evidence of Risk for Post-Trauma Syndrome.
Although the client with tetraplegia does have Impaired Physical Mobility and Self-Care Deficit,
this statement is not evidence of those nursing diagnoses. There is no indication of
Noncompliance.
C) The client's statement is unrealistic and is evidence of Risk for Post-Trauma Syndrome.
Noncompliance.
D) The client's statement is unrealistic and is evidence of Risk for Post-Trauma Syndrome.
Noncompliance.
Page Ref: 916
spinal cord injury.
91

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Nursing: A Concept-Based Approach to Learning, 2e (Pearson)

The Concept of Mobility

A) Risk for Peripheral Neurovascular Dysfunction related to disruption of traction weights

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