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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank
Chapter 31
Question 1
Type: MCSA
The nurse is caring for a client with a diagnosis of a torn ligament in the knee. The client asks the nurse, "What
does the ligament do?" The nurse's best response would include the fact that ligaments:
1. Connect bone to bone.
2. Connect muscle to bone.
3. Encapsulate joints.
4. Connect muscle to muscle.
Correct Answer: 1
Rationale 1: The ligaments connect bone to bone. Tendons connect muscle to bone. Muscles do not connect to
other muscles.
Rationale 2: The ligaments connect bone to bone. Tendons connect muscle to bone. Muscles do not connect to
other muscles.
Rationale 3: The ligaments connect bone to bone. Tendons connect muscle to bone. Muscles do not connect to
other muscles.
Rationale 4: The ligaments connect bone to bone. Tendons connect muscle to bone. Muscles do not connect to
other muscles.
Global Rationale:
Cognitive Level: Remembering
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss the anatomy and physiology of the musculoskeletal system.
Question 2
Type: MCSA
The nurse is caring for a client suspected of having a muscle injury in the left upper arm, and anticipates the
provider will order what diagnostic test?
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. X-ray
2. MRI
3. Myelogram
4. Arthroscopy
Correct Answer: 2
Rationale 1: MRI is the best test for diagnosing soft tissue injuries such as those involving muscles. X-rays are
not highly diagnostic for soft tissue damage, and are better suited for examining bones. Myelograms are done to
diagnose herniated disks. Arthroscopies examine the inside of a joint.
Rationale 2: MRI is the best test for diagnosing soft tissue injuries such as those involving muscles. X-rays are
not highly diagnostic for soft tissue damage, and are better suited for examining bones. Myelograms are done to
diagnose herniated disks. Arthroscopies examine the inside of a joint.
Rationale 3: MRI is the best test for diagnosing soft tissue injuries such as those involving muscles. X-rays are
not highly diagnostic for soft tissue damage, and are better suited for examining bones. Myelograms are done to
diagnose herniated disks. Arthroscopies examine the inside of a joint.
Rationale 4: MRI is the best test for diagnosing soft tissue injuries such as those involving muscles. X-rays are
not highly diagnostic for soft tissue damage, and are better suited for examining bones. Myelograms are done to
diagnose herniated disks. Arthroscopies examine the inside of a joint.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: List diagnostic tests for disorders of the musculoskeletal system.
Question 3
Type: MCSA
The nurse admits a 14-year-old with an edematous painful left forearm after having an accident while driving an
all-terrain vehicle. The x-ray shows a comminuted fracture of the radius and displaced fracture of the ulna. The
nurse anticipates the client's initial treatment will be:
1. External fixation.
2. Internal fixation.
3. Casting.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

4. Traction.
Correct Answer: 2
Rationale 1: Because the fractures are both displaced and comminuted, they cannot be repaired externally, and
will require surgery to approximate the bones prior to casting. Traction might be indicated, depending on the
repair performed after the surgery is completed. The arm cannot be casted until edema subsides to reduce the risk
of circulatory impairment.
Rationale 2: Because the fractures are both displaced and comminuted, they cannot be repaired externally, and
will require surgery to approximate the bones prior to casting. Traction might be indicated, depending on the
repair performed after the surgery is completed. The arm cannot be casted until edema subsides to reduce the risk
of circulatory impairment.
Rationale 3: Because the fractures are both displaced and comminuted, they cannot be repaired externally, and
will require surgery to approximate the bones prior to casting. Traction might be indicated, depending on the
repair performed after the surgery is completed. The arm cannot be casted until edema subsides to reduce the risk
of circulatory impairment.
Rationale 4: Because the fractures are both displaced and comminuted, they cannot be repaired externally, and
will require surgery to approximate the bones prior to casting. Traction might be indicated, depending on the
repair performed after the surgery is completed. The arm cannot be casted until edema subsides to reduce the risk
of circulatory impairment.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify types of skeletal trauma, treatment, potential complications, and nursing care.
Question 4
Type: MCSA
The nurse is caring for an adolescent admitted with a fractured femur who was placed in traction several days ago.
The nurse prepares to perform an initial assessment, and walks into the client's room to find him dyspneic and
reporting severe chest pain. The nurse suspects the client has developed:
1. Pneumonia.
2. Pneumothorax.
3. Myocardial infarction.
4. Fat embolism.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer: 4
Rationale 1: The client is at risk for fat embolism as the result of a fracture of the long bone, producing symptoms
depending on where the embolus travels. In this adolescent's case, the embolus traveled to the lungs and produced
pulmonary symptoms. This can be life-threatening, and rapid intervention is required.
Rationale 2: The client is at risk for fat embolism as the result of a fracture of the long bone, producing symptoms
depending on where the embolus travels. In this adolescent's case, the embolus traveled to the lungs and produced
pulmonary symptoms. This can be life-threatening, and rapid intervention is required.
Rationale 3: The client is at risk for fat embolism as the result of a fracture of the long bone, producing symptoms
depending on where the embolus travels. In this adolescent's case, the embolus traveled to the lungs and produced
pulmonary symptoms. This can be life-threatening, and rapid intervention is required.
Rationale 4: The client is at risk for fat embolism as the result of a fracture of the long bone, producing symptoms
depending on where the embolus travels. In this adolescent's case, the embolus traveled to the lungs and produced
pulmonary symptoms. This can be life-threatening, and rapid intervention is required.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify types of skeletal trauma, treatment, potential complications, and nursing care.
Question 5
Type: MCSA
The nurse working on a postpartum unit includes teaching on osteoporosis prevention for which of the following
clients at greatest risk?
1. Asian-American mother of three
2. German-American mother of two who smokes
3. African-American mother of one who is a dietician
4. The Latino mother of two who is a recovering alcoholic
Correct Answer: 2
Rationale 1: The client at greatest risk is the German-American who smokes, because she has two risk factors. It
is important to use any opportunity for woman at risk for osteoporosis to explain the need for calcium and vitamin
D supplementation.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: The client at greatest risk is the German-American who smokes, because she has two risk factors. It
is important to use any opportunity for woman at risk for osteoporosis to explain the need for calcium and vitamin
D supplementation.
Rationale 3: The client at greatest risk is the German-American who smokes, because she has two risk factors. It
is important to use any opportunity for woman at risk for osteoporosis to explain the need for calcium and vitamin
D supplementation.
Rationale 4: The client at greatest risk is the German-American who smokes, because she has two risk factors. It
is important to use any opportunity for woman at risk for osteoporosis to explain the need for calcium and vitamin
D supplementation.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Define osteoporosis and describe prevention, treatment, and nursing care for a client with
osteoporosis.
Question 6
Type: MCSA
The nurse admits an elderly woman with a diagnosis of osteoporosis. The nurse plans which intervention to
prevent complications related to this diagnosis?
1. Pad the side rails of the bed to prevent fractures.
2. Encourage a moderate exercise program to reduce bone loss.
3. Administer analgesics for pain.
4. Obtain an order from the physician for vitamin K supplements.
Correct Answer: 2
Rationale 1: The best intervention for this client is to encourage a moderate regular exercise program, such as
walking, to reduce the loss of bone mass. While bones become increasingly fragile with osteoporosis, they do not
become so fragile as to require side rail padding. The need for analgesics is not indicated, and is not inherent with
the diagnosis of osteoporosis. Vitamin D, calcium, and phosphorous supplementation, not vitamin K
supplementation, is useful in treating and preventing further bone loss related to osteoporosis.
Rationale 2: The best intervention for this client is to encourage a moderate regular exercise program, such as
walking, to reduce the loss of bone mass. While bones become increasingly fragile with osteoporosis, they do not
become so fragile as to require side rail padding. The need for analgesics is not indicated, and is not inherent with
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

the diagnosis of osteoporosis. Vitamin D, calcium, and phosphorous supplementation, not vitamin K
supplementation, is useful in treating and preventing further bone loss related to osteoporosis.
Rationale 3: The best intervention for this client is to encourage a moderate regular exercise program, such as
walking, to reduce the loss of bone mass. While bones become increasingly fragile with osteoporosis, they do not
become so fragile as to require side rail padding. The need for analgesics is not indicated, and is not inherent with
the diagnosis of osteoporosis. Vitamin D, calcium, and phosphorous supplementation, not vitamin K
supplementation, is useful in treating and preventing further bone loss related to osteoporosis.
Rationale 4: The best intervention for this client is to encourage a moderate regular exercise program, such as
walking, to reduce the loss of bone mass. While bones become increasingly fragile with osteoporosis, they do not
become so fragile as to require side rail padding. The need for analgesics is not indicated, and is not inherent with
the diagnosis of osteoporosis. Vitamin D, calcium, and phosphorous supplementation, not vitamin K
supplementation, is useful in treating and preventing further bone loss related to osteoporosis.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Define osteoporosis and describe prevention, treatment, and nursing care for a client with
osteoporosis.
Question 7
Type: MCSA
In addition to pain management, the nurse's priority of care for clients diagnosed with bone disorders is:
1. Resolving knowledge deficits.
2. Assessing circulation.
3. Promoting self-esteem.
4. Maintaining correct body alignment.
Correct Answer: 4
Rationale 1: The priority of care for all clients with bone disorders is maintaining correct body alignment to
prevent deformities. Knowledge deficits, circulation risks, and self-esteem needs might apply to some clients, but
not every client with a bone disorder will have those needs.
Rationale 2: The priority of care for all clients with bone disorders is maintaining correct body alignment to
prevent deformities. Knowledge deficits, circulation risks, and self-esteem needs might apply to some clients, but
not every client with a bone disorder will have those needs.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: The priority of care for all clients with bone disorders is maintaining correct body alignment to
prevent deformities. Knowledge deficits, circulation risks, and self-esteem needs might apply to some clients, but
not every client with a bone disorder will have those needs.
Rationale 4: The priority of care for all clients with bone disorders is maintaining correct body alignment to
prevent deformities. Knowledge deficits, circulation risks, and self-esteem needs might apply to some clients, but
not every client with a bone disorder will have those needs.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify disorders of bone tissue and describe proper nursing care for them.
Question 8
Type: MCSA
The nurse admits a 75-year-old client with a diagnosis of septicemia who had a cast placed two weeks ago for a
fractured radius. While measuring vital signs, the nurse smells a foul odor emanating from the cast, and suspects:
1. The client might have spilled something into the cast.
2. An infection inside the cast might be the cause of septicemia.
3. The client might not be bathing because of the cast.
4. The odor is the result of the diagnosis of septicemia.
Correct Answer: 2
Rationale 1: A foul odor emanating from the cast indicates the possibility of infection, and could cause septicemia
if not noted and treated immediately. The nurse should report this finding to the RN, and the cast will likely be
removed, or a window cut in the cast, to assess the arm further.
Rationale 2: A foul odor emanating from the cast indicates the possibility of infection, and could cause septicemia
if not noted and treated immediately. The nurse should report this finding to the RN, and the cast will likely be
removed, or a window cut in the cast, to assess the arm further.
Rationale 3: A foul odor emanating from the cast indicates the possibility of infection, and could cause septicemia
if not noted and treated immediately. The nurse should report this finding to the RN, and the cast will likely be
removed, or a window cut in the cast, to assess the arm further.
Rationale 4: A foul odor emanating from the cast indicates the possibility of infection, and could cause septicemia
if not noted and treated immediately. The nurse should report this finding to the RN, and the cast will likely be
removed, or a window cut in the cast, to assess the arm further.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Explain nursing care for a client in a cast or traction.
Question 9
Type: MCMA
The nurse is caring for a client with osteoarthritis, and plans nonpharmacological pain management to include:
(Select all that apply.)
Standard Text: Select all that apply.
1. X-rays.
2. Moderate activity plan.
3. Ice pack to the most painful area.
4. Application of warm moist heat.
5. NSAIDs.
Correct Answer: 2,4
Rationale 1: Heat, not ice, can be applied to the area, and moist heat is most effective at reducing pain and
inflammation. A common approach by physical therapy includes paraffin wax treatments, where the client inserts
the painful joint into warm liquid paraffin, which holds in the heat for an extended period of time and can be very
comforting. Joints tend to stiffen and become more painful during periods of inactivity, so a moderate activity
plan can help to prevent this. NSAIDs may be administered, but this is pharmacological treatment, not
nonpharmacological treatment. X-rays may be performed for diagnosis but do not treat the pain.
Rationale 2: Heat, not ice, can be applied to the area, and moist heat is most effective at reducing pain and
inflammation. A common approach by physical therapy includes paraffin wax treatments, where the client inserts
the painful joint into warm liquid paraffin, which holds in the heat for an extended period of time and can be very
comforting. Joints tend to stiffen and become more painful during periods of inactivity, so a moderate activity
plan can help to prevent this. NSAIDs may be administered, but this is pharmacological treatment, not
nonpharmacological treatment. X-rays may be performed for diagnosis but do not treat the pain.
Rationale 3: Heat, not ice, can be applied to the area, and moist heat is most effective at reducing pain and
inflammation. A common approach by physical therapy includes paraffin wax treatments, where the client inserts
the painful joint into warm liquid paraffin, which holds in the heat for an extended period of time and can be very
comforting. Joints tend to stiffen and become more painful during periods of inactivity, so a moderate activity
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

plan can help to prevent this. NSAIDs may be administered, but this is pharmacological treatment, not
nonpharmacological treatment. X-rays may be performed for diagnosis but do not treat the pain.
Rationale 4: Heat, not ice, can be applied to the area, and moist heat is most effective at reducing pain and
inflammation. A common approach by physical therapy includes paraffin wax treatments, where the client inserts
the painful joint into warm liquid paraffin, which holds in the heat for an extended period of time and can be very
comforting. Joints tend to stiffen and become more painful during periods of inactivity, so a moderate activity
plan can help to prevent this. NSAIDs may be administered, but this is pharmacological treatment, not
nonpharmacological treatment. X-rays may be performed for diagnosis but do not treat the pain.
Rationale 5: Heat, not ice, can be applied to the area, and moist heat is most effective at reducing pain and
inflammation. A common approach by physical therapy includes paraffin wax treatments, where the client inserts
the painful joint into warm liquid paraffin, which holds in the heat for an extended period of time and can be very
comforting. Joints tend to stiffen and become more painful during periods of inactivity, so a moderate activity
plan can help to prevent this. NSAIDs may be administered, but this is pharmacological treatment, not
nonpharmacological treatment. X-rays may be performed for diagnosis but do not treat the pain.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Distinguish among four inflammatory disorders of the musculoskeletal system and nursing
care for them.
Question 10
Type: MCSA
The nurse examines a client who had a total knee replacement and has been placed in a continuous passive motion
machine. The client asks, "What is the purpose of that machine?" The nurse explains the purpose by saying:
1. "The machine is used to prevent scarring of the incision site and keep the knee elevated."
2. "The machine prevents rusting of the artificial joint, which could occur because of the fluids in your body
coming in contact with it."
3. "The machine helps to decrease swelling and maintain normal function until you can begin exercising your
knee independently."
4. "The machine helps to provide exercise so you don't gain weight while your activity level is diminished."
Correct Answer: 3
Rationale 1: The purpose of the continuous passive motion machine is to decrease swelling and maintain normal
function of the joint until the client can begin exercising the joint independently of the machine.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 2: The purpose of the continuous passive motion machine is to decrease swelling and maintain normal
function of the joint until the client can begin exercising the joint independently of the machine.
Rationale 3: The purpose of the continuous passive motion machine is to decrease swelling and maintain normal
function of the joint until the client can begin exercising the joint independently of the machine.
Rationale 4: The purpose of the continuous passive motion machine is to decrease swelling and maintain normal
function of the joint until the client can begin exercising the joint independently of the machine.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: List the common nursing interventions in joint replacement surgery.
Question 11
Type: MCSA
The nurse working on an acute pediatric unit is caring for an 8-year-old child who is profoundly mentally retarded
with significant developmental delays and cerebral palsy that limits the child to a wheelchair. The child was
admitted for a significant scoliosis, and has had surgery to fuse the spine, with insertion of rods on both sides of
the spinal column. In addition to preventing infection and pain management, the nurse's priority of care is:
1. Careful movement and repositioning of the client.
2. Supporting family coping measures.
3. Providing respite care for the primary caregiver.
4. Encouraging ambulation as soon as possible.
Correct Answer: 1
Rationale 1: Because of the rod placement, this child must be moved and repositioned carefully to avoid strain on
the rods. Insufficient information is available about the family's coping mechanism to know if it is healthy or
dysfunctional. Admission to the hospital is respite care for the family. This child is unable to ambulate, and is
wheelchair-bound.
Rationale 2: Because of the rod placement, this child must be moved and repositioned carefully to avoid strain on
the rods. Insufficient information is available about the family's coping mechanism to know if it is healthy or
dysfunctional. Admission to the hospital is respite care for the family. This child is unable to ambulate, and is
wheelchair-bound.
Rationale 3: Because of the rod placement, this child must be moved and repositioned carefully to avoid strain on
the rods. Insufficient information is available about the family's coping mechanism to know if it is healthy or
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

dysfunctional. Admission to the hospital is respite care for the family. This child is unable to ambulate, and is
wheelchair-bound.
Rationale 4: Because of the rod placement, this child must be moved and repositioned carefully to avoid strain on
the rods. Insufficient information is available about the family's coping mechanism to know if it is healthy or
dysfunctional. Admission to the hospital is respite care for the family. This child is unable to ambulate, and is
wheelchair-bound.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe the care of the client with spinal disorders.
Question 12
Type: MCSA
The nurse working in the Emergency Department admits a client whose left arm hangs lower than the right arm
and who is reporting severe left shoulder pain. The nurse's care, until the client is seen by the physician, is aimed
at:
1. Reducing anxiety.
2. Preventing movement of the right arm.
3. Preventing movement of the left arm.
4. Knowledge deficit.
Correct Answer: 3
Rationale 1: The client likely has a dislocated left shoulder, and the nurse should aim care at preventing
movement of the arm, which can worsen inflammation and stretching of ligaments and tendons until the bone is
placed back into position. The client's knowledge and anxiety level is unknown.
Rationale 2: The client likely has a dislocated left shoulder, and the nurse should aim care at preventing
movement of the arm, which can worsen inflammation and stretching of ligaments and tendons until the bone is
placed back into position. The client's knowledge and anxiety level is unknown.
Rationale 3: The client likely has a dislocated left shoulder, and the nurse should aim care at preventing
movement of the arm, which can worsen inflammation and stretching of ligaments and tendons until the bone is
placed back into position. The client's knowledge and anxiety level is unknown.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: The client likely has a dislocated left shoulder, and the nurse should aim care at preventing
movement of the arm, which can worsen inflammation and stretching of ligaments and tendons until the bone is
placed back into position. The client's knowledge and anxiety level is unknown.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify the most common joint and muscle disorders and nursing interventions for them.
Question 13
Type: MCSA
The nurse working in an outpatient clinic admits a client who is diagnosed with a sprained ankle. The nurse
teaches the client to:
1. Keep the ankle off the floor.
2. Keep ice on the ankle for the next week.
3. Keep an ace bandage wrapped around the ankle, especially when walking.
4. Avoid weight bearing for two weeks.
Correct Answer: 3
Rationale 1: While the client should rest the ankle, the time period will be dependent on the severity of the sprain,
and could range from a few days to a few months. Ice should be applied for 48 hours and then heat may be
prescribed. The ace bandage should be kept on, especially if weight bearing, to support the ankle.
Rationale 2: While the client should rest the ankle, the time period will be dependent on the severity of the sprain,
and could range from a few days to a few months. Ice should be applied for 48 hours and then heat may be
prescribed. The ace bandage should be kept on, especially if weight bearing, to support the ankle.
Rationale 3: While the client should rest the ankle, the time period will be dependent on the severity of the sprain,
and could range from a few days to a few months. Ice should be applied for 48 hours and then heat may be
prescribed. The ace bandage should be kept on, especially if weight bearing, to support the ankle.
Rationale 4: While the client should rest the ankle, the time period will be dependent on the severity of the sprain,
and could range from a few days to a few months. Ice should be applied for 48 hours and then heat may be
prescribed. The ace bandage should be kept on, especially if weight bearing, to support the ankle.
Global Rationale:
Cognitive Level: Applying
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Client Need: Physiological Integrity


Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify the most common joint and muscle disorders and nursing interventions for them.
Question 14
Type: MCSA
Which of the following clients would the nurse consider at risk for use of heat or cold applications?
1. A 68-year-old client with advanced Alzheimer's disease
2. A 42-year-old client recently diagnosed with diabetes mellitus
3. A 24-year-old with rheumatoid arthritis
4. A 12-year-old diagnosed with a newly fractured right humerus
Correct Answer: 1
Rationale 1: The confused client with Alzheimer's disease might have reduced ability to perceive the discomfort
associated with heat and cold applications that indicate tissue damage, so the nurse must assess the area carefully.
Rationale 2: The confused client with Alzheimer's disease might have reduced ability to perceive the discomfort
associated with heat and cold applications that indicate tissue damage, so the nurse must assess the area carefully.
Rationale 3: The confused client with Alzheimer's disease might have reduced ability to perceive the discomfort
associated with heat and cold applications that indicate tissue damage, so the nurse must assess the area carefully.
Rationale 4: The confused client with Alzheimer's disease might have reduced ability to perceive the discomfort
associated with heat and cold applications that indicate tissue damage, so the nurse must assess the area carefully.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Discuss advantages and disadvantages of heat and cold therapy for clients with
musculoskeletal disorders.
Question 15
Type: MCSA
The client enters the outpatient clinic and says, "I think I have the flu. I'm so tired, I have no appetite, and
everything hurts." The nurse assesses the client and finds a rash over the nose and on the cheeks, and suspects a
diagnosis of:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Fibromyalgia.
2. Systemic lupus erythematosus.
3. Lyme disease.
4. Gout.
Correct Answer: 2
Rationale 1: The rash over the nose and cheeks is sometimes called a butterfly rash, and is classic for the
diagnosis of systemic lupus erythematosus, although not every client diagnosed with this disorder will have this
rash.
Rationale 2: The rash over the nose and cheeks is sometimes called a butterfly rash, and is classic for the
diagnosis of systemic lupus erythematosus, although not every client diagnosed with this disorder will have this
rash.
Rationale 3: The rash over the nose and cheeks is sometimes called a butterfly rash, and is classic for the
diagnosis of systemic lupus erythematosus, although not every client diagnosed with this disorder will have this
rash.
Rationale 4: The rash over the nose and cheeks is sometimes called a butterfly rash, and is classic for the
diagnosis of systemic lupus erythematosus, although not every client diagnosed with this disorder will have this
rash.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe nursing care for clients with SLE or fibromyalgia.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.