CONCEPT BASED ASSESSMENT RN LEVEL 2 / RN
CONCEPT BASED ASSESSMENT LEVEL 2 NEWEST EXAM
ACTUAL EXAM REAL QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (100% correct
verified answers) A NEW UPDATED VERSION |ALREADY
GRADED A+
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:
CONCEPT BASED ASSESSMENT LEVEL 2 NEWEST EXAM
ACTUAL EXAM REAL QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (100% correct
verified answers) A NEW UPDATED VERSION |ALREADY
GRADED A+
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:
