A CONCEPT BASED APPROACH TO LEARNING//
ACTUARATE HUMAN CASE ANALYSIS ( expert reviews )
WITH ALL CORRECT ANSWERS.
Page Ref: 883
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
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
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. - CORRECT ANSWERS-
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 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. - CORRECT
ANSWERS-A
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
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. - CORRECT
ANSWERS-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
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. - CORRECT ANSWERS-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
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. - CORRECT ANSWERS-A
Explanation: A) Contraction of skeletal muscle attached to bones via tendons creates
movement. Smooth muscle is not attached to bones. Cartilage is not vascular. The axial
skeleton is not part of the lower extremities.
Page Ref: 820
Cognitive Level: Creating
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
1. Summarize the physiology of the musculoskeletal system related to mobility.
2) A 70-year-old client is diagnosed with bone spurs of the vertebral column. The nurse
should plan which priority action?
A) Implement low-level exercise program.
B) Assess pain management.
C) Teach relaxation techniques.
D) Refer to a dietitian. - CORRECT ANSWERS-B
Explanation:
Osteoarthritis seen in normal aging can lead to the formation of bone spurs that make
movement painful. The nurse should assess pain management prior to implementing an
exercise program, teaching relaxation exercises, or referring to a dietitian.
Page Ref: 824
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
2. Examine the relationship between mobility and other concepts/systems.
, 3) A preadolescent patient who fell from a balance beam in Physical Education class
reports ankle pain. The nurse assesses edema and ecchymosis. What initial cause and
intervention will be anticipated?
A) Neurological evaluation for Parkinson's disease
B) Rest, ice, compression and elevation (RICE) for ankle sprain.
C) Brace fitting for scoliosis
D) Colchicine for gout - CORRECT ANSWERS-B
Explanation:
RICE is used to decrease swelling and pain for ankle sprain. Parkinson's disease
usually presents with tremors in clients over 50. Scoliosis is an abnormal curvature of
the spine. There is no information suggesting scoliosis. Gout affecting mobility is caused
by uric acid buildup, usually in a joint in the toe.
Page Ref: 827
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
3. Identify commonly occurring alterations in mobility and their related therapies.
4) The nurse detects an exaggerated concave curvature of the lumbar spine of a client.
Which conclusion about this assessment is correct?
A) Abnormal kyphosis is noted during range-of-motion assessment of a child.
B) Normal scoliosis is observed during the joint assessment of an older man.
C) Lordosis is commonly seen in the gait and posture assessment of a pregnant
woman.
D) Crepitus is commonly found during the assessment interview of a middle-aged
woman. - CORRECT ANSWERS-C
Explanation:
An exaggerated concave curvature of the lumbar spine is lordosis and is seen in the
gait and posture assessment of pregnant women or obese clients. Scoliosis is not
normal. A range-of-motion assessment, joint assessment, or interview will not detect
lordosis.
Page Ref: 830
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
4. Differentiate common assessment procedures used to examine musculoskeletal
health across the life span.
5) An older client is demonstrating signs of osteoporosis. The nurse should instruct the
client on which tests to aid in the diagnosis of this disorder?
Select all that apply.
ACTUARATE HUMAN CASE ANALYSIS ( expert reviews )
WITH ALL CORRECT ANSWERS.
Page Ref: 883
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Planning
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
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. - CORRECT ANSWERS-
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 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. - CORRECT
ANSWERS-A
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
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. - CORRECT
ANSWERS-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
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. - CORRECT ANSWERS-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
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. - CORRECT ANSWERS-A
Explanation: A) Contraction of skeletal muscle attached to bones via tendons creates
movement. Smooth muscle is not attached to bones. Cartilage is not vascular. The axial
skeleton is not part of the lower extremities.
Page Ref: 820
Cognitive Level: Creating
Client Need: Health Promotion and Maintenance
Nursing Process: Assessment
1. Summarize the physiology of the musculoskeletal system related to mobility.
2) A 70-year-old client is diagnosed with bone spurs of the vertebral column. The nurse
should plan which priority action?
A) Implement low-level exercise program.
B) Assess pain management.
C) Teach relaxation techniques.
D) Refer to a dietitian. - CORRECT ANSWERS-B
Explanation:
Osteoarthritis seen in normal aging can lead to the formation of bone spurs that make
movement painful. The nurse should assess pain management prior to implementing an
exercise program, teaching relaxation exercises, or referring to a dietitian.
Page Ref: 824
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
2. Examine the relationship between mobility and other concepts/systems.
, 3) A preadolescent patient who fell from a balance beam in Physical Education class
reports ankle pain. The nurse assesses edema and ecchymosis. What initial cause and
intervention will be anticipated?
A) Neurological evaluation for Parkinson's disease
B) Rest, ice, compression and elevation (RICE) for ankle sprain.
C) Brace fitting for scoliosis
D) Colchicine for gout - CORRECT ANSWERS-B
Explanation:
RICE is used to decrease swelling and pain for ankle sprain. Parkinson's disease
usually presents with tremors in clients over 50. Scoliosis is an abnormal curvature of
the spine. There is no information suggesting scoliosis. Gout affecting mobility is caused
by uric acid buildup, usually in a joint in the toe.
Page Ref: 827
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
3. Identify commonly occurring alterations in mobility and their related therapies.
4) The nurse detects an exaggerated concave curvature of the lumbar spine of a client.
Which conclusion about this assessment is correct?
A) Abnormal kyphosis is noted during range-of-motion assessment of a child.
B) Normal scoliosis is observed during the joint assessment of an older man.
C) Lordosis is commonly seen in the gait and posture assessment of a pregnant
woman.
D) Crepitus is commonly found during the assessment interview of a middle-aged
woman. - CORRECT ANSWERS-C
Explanation:
An exaggerated concave curvature of the lumbar spine is lordosis and is seen in the
gait and posture assessment of pregnant women or obese clients. Scoliosis is not
normal. A range-of-motion assessment, joint assessment, or interview will not detect
lordosis.
Page Ref: 830
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing Process: Assessment
4. Differentiate common assessment procedures used to examine musculoskeletal
health across the life span.
5) An older client is demonstrating signs of osteoporosis. The nurse should instruct the
client on which tests to aid in the diagnosis of this disorder?
Select all that apply.
