ES
ID
U
EG
R
O
SC
, ES
ID
U
EG
R
O
SC
, ES
ID
U
EG
R
O
SC
, JHGFDSA
5) Which is the most important question the nurse should ask a client before performing a routine
musculoskeletal assessment?
A) "Do you exercise every day?"
B) "Do you have a history of any sports injuries?"
C) "Do you take a hot bath to relax your muscles?"
D) "Do you want pain medication before I begin?"
Answer: B
Explanation: A) Knowing if a client exercises is an important question but knowing if there are
SC
any sports injuries to know about first, is most important before doing a routine musculoskeletal
assessment.
B) It is important to note if the client has a history of any sports injuries first to know what the
client will or will not be able to do during a routine musculoskeletal assessment.
C) Knowing if the client takes a hot bath to relax the muscles is not the most important to ask
before performing a routine musculoskeletal assessment.
D) To know if a client is experiencing any pain is an important question; however, this question
O
is assuming the client is in pain by asking if the client wants a pain medication before beginning
a routine musculoskeletal assessment.
Page Ref: 62
R
Cognitive Level: Analyzing
Client Need/Sub: Safety and Infection Control: Accident/Error/Injury Prevention
Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies: Safety
AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice
EG
NLN Competencies: Quality and Safety
6) A client's daughter mentions to the nurse that her mom seems to have a decline in mental
status and seems to be forgetting many things in their conversation since this hospitalization.
Which is the best response by the nurse?
A) "Give your mom time, because it will take her a little longer when answering questions."
U
B) "Let me check the cranial nerve function to see if there is a defect in her mental status."
C) "You do not need to worry. This decline is part of the normal process of aging."
D) "If you bring some things from her home, it might reduce the confusion."
Answer: D
ID
Explanation: A) This is expected to give some older adults time to respond, but the daughter is
concerned about her forgetting, not the length of the response.
B) Cranial nerve function is an assessment of the cranial nerves and not the mental status of a
client.
C) A decline in mental status is not a normal result of aging, so this response is not true.
ES
D) The stress of being in unfamiliar situations can cause confusion in some older adults.
Page Ref: 68
Cognitive Level: Analyzing
Client Need/Sub: Psychosocial Integrity: Therapeutic Environment
Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient-
Centered Care
AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice
NLN Competencies: Context and Environment
JHGFDSA
ID
U
EG
R
O
SC
, ES
ID
U
EG
R
O
SC
, ES
ID
U
EG
R
O
SC
, JHGFDSA
5) Which is the most important question the nurse should ask a client before performing a routine
musculoskeletal assessment?
A) "Do you exercise every day?"
B) "Do you have a history of any sports injuries?"
C) "Do you take a hot bath to relax your muscles?"
D) "Do you want pain medication before I begin?"
Answer: B
Explanation: A) Knowing if a client exercises is an important question but knowing if there are
SC
any sports injuries to know about first, is most important before doing a routine musculoskeletal
assessment.
B) It is important to note if the client has a history of any sports injuries first to know what the
client will or will not be able to do during a routine musculoskeletal assessment.
C) Knowing if the client takes a hot bath to relax the muscles is not the most important to ask
before performing a routine musculoskeletal assessment.
D) To know if a client is experiencing any pain is an important question; however, this question
O
is assuming the client is in pain by asking if the client wants a pain medication before beginning
a routine musculoskeletal assessment.
Page Ref: 62
R
Cognitive Level: Analyzing
Client Need/Sub: Safety and Infection Control: Accident/Error/Injury Prevention
Standards: Nursing Process: Assessment | Learning Outcome: 1.5 | QSEN Competencies: Safety
AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice
EG
NLN Competencies: Quality and Safety
6) A client's daughter mentions to the nurse that her mom seems to have a decline in mental
status and seems to be forgetting many things in their conversation since this hospitalization.
Which is the best response by the nurse?
A) "Give your mom time, because it will take her a little longer when answering questions."
U
B) "Let me check the cranial nerve function to see if there is a defect in her mental status."
C) "You do not need to worry. This decline is part of the normal process of aging."
D) "If you bring some things from her home, it might reduce the confusion."
Answer: D
ID
Explanation: A) This is expected to give some older adults time to respond, but the daughter is
concerned about her forgetting, not the length of the response.
B) Cranial nerve function is an assessment of the cranial nerves and not the mental status of a
client.
C) A decline in mental status is not a normal result of aging, so this response is not true.
ES
D) The stress of being in unfamiliar situations can cause confusion in some older adults.
Page Ref: 68
Cognitive Level: Analyzing
Client Need/Sub: Psychosocial Integrity: Therapeutic Environment
Standards: Nursing Process: Planning | Learning Outcome: 1.6 | QSEN Competencies: Patient-
Centered Care
AACN Ess. Comps.: Essential IX: Baccalaureate Generalist Nursing Practice
NLN Competencies: Context and Environment
JHGFDSA
