Mobility a concept based approach to learning exam

7. Evaluate expected outcomes for an individual with multiple sclerosis. 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.

A Explanation: 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. Page Ref: 881 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of Parkinson disease. 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."

A Explanation: 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. Page Ref: 896 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

7. Evaluate expected outcomes for an individual with osteoarthritis. 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

A Explanation: 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. Page Ref: 896 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

2. Identify risk factors and prevention methods associated with multiple sclerosis. 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.

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. Page Ref: 876-877 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

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. 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.

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. Page Ref: 841 Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Assessment

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with a fracture. 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."

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. Page Ref: 870 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control Nursing Process: Analysis

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.

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

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

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

4. Formulate priority nursing diagnoses appropriate for an individual with osteoarthritis. 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.

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. Page Ref: 889 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning

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. 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.

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. Page Ref: 846 Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Evaluation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of osteoarthritis. 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

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. Page Ref: 887 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

4. Formulate priority nursing diagnoses appropriate for an individual with multiple sclerosis. 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.

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. Page Ref: 883 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with multiple sclerosis. 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

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. Page Ref: 883 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning

2. Identify risk factors and prevention methods associated with spinal cord injury. 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

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. Page Ref: 916 Cognitive Level: Analyzing Client Need: Psychosocial Integrity Nursing Process: Analysis

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. 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.

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. Page Ref: 883 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

4. Formulate priority nursing diagnoses appropriate for an individual with back problems. 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.

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. Page Ref: 845 Cognitive Level: Creating Client Need: Physiological Integrity Nursing Process: Planning

2. Identify risk factors and prevention methods associated with hip fractures. 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.

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. Page Ref: 870 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

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."

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

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with multiple sclerosis. 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?? Select all that apply. 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

A, B Explanation: 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. Page Ref: 880 Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing Process: Analysis

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with osteoarthritis. 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? Select all that apply. A) Osteoarthritis B) Rheumatoid arthritis C) Septic arthritis D) Gout E) Trauma

A, B Explanation: 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. Page Ref: 888 Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Implementation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with back problems. 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? Select all that apply. 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.

A, B, D Explanation: 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. Page Ref: 850 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Caring

4. Formulate priority nursing diagnoses appropriate for an individual with hip fractures. 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? Select all that apply. 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."

A, C Explanation: 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. Page Ref: 874 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with Parkinson disease. 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? Select all that apply. 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

A, C, D, E Explanation: 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. Page Ref: 904 Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care Nursing Process: Communication and Documentation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with fractures. 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? Select all that apply. 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."

A, D Explanation: 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. Page Ref: 862 Cognitive Level: Creating Client Need: Physiological Integrity Nursing Process: Implementation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with hip fractures. 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? Select all that apply. 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.

A, D, E Explanation: 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. Page Ref: 874 Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing Process: Evaluation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of fractures. 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

B Explanation: 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. Page Ref: 857 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Assessment

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with Parkinson disease. 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."

B Explanation: 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. Page Ref: 899 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with a fracture. 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

B Explanation: 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. Page Ref: 867 Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Evaluation

7. Evaluate expected outcomes for an individual with Parkinson disease. 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."

B Explanation: 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. Page Ref: 896 Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Evaluation

2. Identify risk factors and prevention methods associated with osteoarthritis. 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.

B Explanation: 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. Page Ref: 887 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

6. Plan evidence-based care for an individual with osteoarthritis and his or her family in collaboration with other members of the healthcare team. 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."

B Explanation: 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. Page Ref: 893 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

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. 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

B Explanation: 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. Page Ref: 863 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning

6. Plan evidence-based care for an individual with osteoarthritis and his or her family in collaboration with other members of the healthcare team. 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

B Explanation: 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. Page Ref: 888-889 Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Planning

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.

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

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

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

2. Identify risk factors and prevention methods associated with back problems. 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

B Explanation: 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. Page Ref: 846 Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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

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. Illustrate the nursing process in providing culturally competent care across the life span for individuals with Parkinson disease. 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

B Explanation: 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. Page Ref: 903 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with back problems. 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

B Explanation: 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. Page Ref: 854 Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing Process: Assessment

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of hip fractures. 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.

B Explanation: 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. Page Ref: 870 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

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. 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.

B Explanation: 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. Page Ref: 845 Cognitive Level: Analyzing Client Need: Psychosocial Integrity Nursing Process: Caring

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with hip fractures. 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

B Explanation: 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. Page Ref: 873 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Diagnosis

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with osteoarthritis. 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

B Explanation: 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. Page Ref: 891 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

6. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with Parkinson disease. 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.

B Explanation: 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. Page Ref: 909-910 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

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. 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.

B Explanation: 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. Page Ref: 912 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

4. Formulate priority nursing diagnoses appropriate for an individual with a fracture. 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.

B Explanation: 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. Page Ref: 861 Cognitive Level: Creating Client Need: Physiological Integrity Nursing Process: Implementation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with a hip fracture. 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? Select all that apply. 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.

B, C, D Explanation: 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. Page Ref: 873 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

2. Identify risk factors and prevention methods associated with multiple sclerosis. 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? Select all that apply. 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."

B, C, D Explanation: 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. Page Ref: 877 Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing Process: Implementation

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

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

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

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

7. Evaluate expected outcomes for an individual with a spinal cord injury. 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? Select all that apply. 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.

B, C, D, E Explanation: 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. Page Ref: 910 Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Assessment

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with a spinal cord injury. 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? Select all that apply. 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.

B, C, E Explanation: 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. Page Ref: 916 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

2. Identify risk factors and prevention methods associated with fractures. 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? Select all that apply. 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.

B, E Explanation: 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. Page Ref: 857 Cognitive Level: Creating Client Need: Psychosocial Integrity: Abuse or Neglect Nursing Process: Implementation

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.

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

7. Evaluate expected outcomes for an individual with osteoarthritis. 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.

C Explanation: 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. Page Ref: 890 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

8. Employ evidence-based caring interventions for an individual with hip fractures. 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

C Explanation: 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. Page Ref: 871 Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing Process: Analysis

6. Plan evidence-based care for an individual with Parkinson disease and his or her family in collaboration with other members of the healthcare team. 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.

C Explanation: 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. Page Ref: 904 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

8. Employ evidence-based caring interventions for an individual with back problems. 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.

C Explanation: 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. Page Ref: 840 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Planning

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with multiple sclerosis. 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.

C Explanation: 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. Page Ref: 883 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning

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

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

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of multiple sclerosis. 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

C Explanation: 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. Page Ref: 877 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with multiple sclerosis. 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

C Explanation: 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. Page Ref: 886 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

4. Formulate priority nursing diagnoses appropriate for an individual with Parkinson disease. 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.

C Explanation: 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. Page Ref: 904 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

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. 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

C Explanation: 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. Page Ref: 877 Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing Process: Assessment

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of spinal cord injury. 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

C Explanation: 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. Page Ref: 913 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

2. Identify risk factors and prevention methods associated with hip fractures. 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.

C Explanation: 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. Page Ref: 874 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

7. Evaluate expected outcomes for an individual with Parkinson disease. 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.

C Explanation: 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. Page Ref: 904-905 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation

7. Evaluate expected outcomes for an individual with a hip fracture. 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

C Explanation: 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. Page Ref: 877 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

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. 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.

C Explanation: 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. Page Ref: 861 Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Planning

2. Identify risk factors and prevention methods associated with spinal cord injury. 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.

C Explanation: 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. Page Ref: 913 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Implementation

7. Evaluate expected outcomes for an individual with a spinal cord injury. 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

C Explanation: 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. Page Ref: 914 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with a spinal cord injury. 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

C Explanation: 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. Page Ref: 916 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

7. Evaluate expected outcomes for an individual with a hip fracture. 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

D Explanation: D) 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. Page Ref: 871 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Assessment

4. Formulate priority nursing diagnoses appropriate for an individual with a spinal cord injury. 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? Select all that apply. 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.

D, E Explanation: 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. Page Ref: 911 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Planning

2. Identify risk factors and prevention methods associated with back problems. 3) A preadolescent patient is recovering from spinal fusion surgery for scoliosis. Which interventions would be appropriate related to movement restrictions and pain? Select all that apply. 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.

A, C, D Explanation: 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. Page Ref: 845 Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Nursing Process: Implementation

6. Plan evidence-based care for an individual with osteoarthritis and his or her family in collaboration with other members of the healthcare team. 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? Select all that apply. 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.

B, C, E Explanation: 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. Page Ref: 891 Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing Process: Evaluation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of Parkinson disease. 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? Select all that apply. A) Diarrhea B) Dystonia C) Retropulsion D) Hyperphonia E) Festination

B, C, E Explanation: 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. Page Ref: 903 Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Assessment

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of spinal cord injury. 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."

C Explanation: 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. Page Ref: 908 Cognitive Level: Applying Client Need: Health Promotion and Maintenance Nursing Process: Implementation

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with osteoarthritis. 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.

D Explanation: 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. Page Ref: 890 Cognitive Level: Applying Client Need: Health Promotion and Maintenance 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

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

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with back problems. 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%

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 Cognitive Level: Creating Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing Process: Assessment

2. Identify risk factors and prevention methods associated with Parkinson disease. 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.

A Explanation: 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. Page Ref: 902 Cognitive Level: Applying Client Need: Psychosocial Integrity Nursing Process: Implementation

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of fractures. 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.

B Explanation: 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. Page Ref: 858 Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential Nursing Process: Assessment

5. Summarize therapies used by interdisciplinary teams in the collaborative care of an individual with back problems. 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.

C Explanation: 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. Page Ref: 843 Cognitive Level: Applying Client Need: Physiological Integrity Nursing Process: Planning

1. Describe the pathophysiology, etiology, clinical manifestations, and direct and indirect causes of back problems. 2) During a health screening, the nurse analyzes that which client is at the highest risk for back problems? Select all that apply. 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

C, D, E Explanation: 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. Page Ref: 841 Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Nursing Process: Assessment

7. Evaluate expected outcomes for an individual with back problems. 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? Select all that apply. 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

C, D, E Explanation: 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. Page Ref: 849 Cognitive Level: Creating Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care Nursing Process: Implementation

6. Plan evidence-based care for an individual with a hip fracture and his or her family in collaboration with other members of the healthcare team. 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

D Explanation: D) 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. Page Ref: 873 Cognitive Level: Analyzing Client Need: Physiological Integrity Nursing Process: Evaluation

3. Illustrate the nursing process in providing culturally competent care across the life span for individuals with fractures. 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.

D Explanation: D) 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. Page Ref: 863 Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort Nursing Process: Evaluation