Test Bank For Nursing A Concept Based Approach to Learning
3rd Edition Pearson Education | 9780134616803 | All Chapters
with Answers and Rationals
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.
Page Ref: 820
Cognitive Level: Creating
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
1. Summarize the physiology of the musculoskeletal system related to mobility.
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:
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.
Page Ref: 824
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
2. Examine the relationship between mobility and other concepts/systems.
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:
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.
Page Ref: 827
Cognitive Level: Analyzing
Client Need: Physiological Integrity
,Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
3. Identify commonly occurring alterations in mobility and their related therapies.
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:
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.
Page Ref: 830
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
4. Differentiate common assessment procedures used to examine musculoskeletal health across the
life span.
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:
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.
Page Ref: 835-836
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Implementation
5. Describe diagnostic and laboratory tests to determine the individual's mobility status.
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
Cognitive Level: Creating
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Implementation
6. Explain management of musculoskeletal health and prevention of immobility.
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.
Page Ref: 820
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
7. Demonstrate the nursing process in providing culturally competent and caring interventions across
the life span for individuals with common alterations in mobility.
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.
Page Ref: 837
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
8. Compare and contrast common independent and collaborative interventions for clients with
alterations in mobility.
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:
, 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.
Page Ref: 835
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Analysis
4. Differentiate common assessment procedures used to examine musculoskeletal health across the
life span.
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:
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.
Page Ref: 838
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
Nursing Process: Implementation/Teaching and Learning
7. Demonstrate the nursing process in providing culturally competent and caring interventions across
the life span for individuals with common alterations in mobility.
11) The nurse contacts the provider to question an order to administer 1,000 mg aspirin to which
clients?
Select all that apply.
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:
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.
Page Ref: 838
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing Process: Implementation
8. Compare and contrast common independent and collaborative interventions for clients with
alterations in mobility.
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.
3rd Edition Pearson Education | 9780134616803 | All Chapters
with Answers and Rationals
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.
Page Ref: 820
Cognitive Level: Creating
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
1. Summarize the physiology of the musculoskeletal system related to mobility.
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:
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.
Page Ref: 824
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
2. Examine the relationship between mobility and other concepts/systems.
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:
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.
Page Ref: 827
Cognitive Level: Analyzing
Client Need: Physiological Integrity
,Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
3. Identify commonly occurring alterations in mobility and their related therapies.
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:
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.
Page Ref: 830
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
4. Differentiate common assessment procedures used to examine musculoskeletal health across the
life span.
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:
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.
Page Ref: 835-836
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Implementation
5. Describe diagnostic and laboratory tests to determine the individual's mobility status.
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
Cognitive Level: Creating
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Implementation
6. Explain management of musculoskeletal health and prevention of immobility.
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.
Page Ref: 820
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Nursing Process: Implementation
7. Demonstrate the nursing process in providing culturally competent and caring interventions across
the life span for individuals with common alterations in mobility.
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.
Page Ref: 837
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Nursing Process: Implementation
8. Compare and contrast common independent and collaborative interventions for clients with
alterations in mobility.
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:
, 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.
Page Ref: 835
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing Process: Analysis
4. Differentiate common assessment procedures used to examine musculoskeletal health across the
life span.
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:
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.
Page Ref: 838
Cognitive Level: Applying
Client Need: Safe and Effective Care Environment
Client Need Sub: Safety and Infection Control
Nursing Process: Implementation/Teaching and Learning
7. Demonstrate the nursing process in providing culturally competent and caring interventions across
the life span for individuals with common alterations in mobility.
11) The nurse contacts the provider to question an order to administer 1,000 mg aspirin to which
clients?
Select all that apply.
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:
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.
Page Ref: 838
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing Process: Implementation
8. Compare and contrast common independent and collaborative interventions for clients with
alterations in mobility.
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.
