Unit 4   

1.  ___  Comparing distance walked to distance specified in goal. 
2.  ___  Doing range of motion exercises with the client to increase his strength 
3.  ___  Asking the client how far he walked at home before he had his surgery 
4.  ___  Writing an intervention to ambulate the client TID. 
5.  ___  Comparing the client’s strength and  range of motion of his joints to what is 
              normally seen in a 70 year old man 
6.  ___  Clustering the following data:  c/o weakness, ambulates with the assist of 2 people, 
              limited ROM of knees due to surgery 
7.  ___  Measuring the client’s blood pressure in lying and standing position 
8.  ___  Prioritizing the list of nursing diagnoses 
9.  ___  Writing the following on the nursing care plan “ Altered mobility r/t weakness and limited 
              ROM of knees as evidenced by inability to ambulate independently” 
10.  ___   Writing the following on the nursing care plan “ Client will ambulate 2 blocks 
                independently  in 6 weeks.” 
11.  ___   Writing the following on the nursing care plan “ Client will state the reason for ROM 
                exercises by 12 pm today.” 
12.  ___  Teaching the client why ROM exercises are important 
 
13.  Which of the numbers above is an OUTCOME criteria? 
a.  # 2 
b.  #5 
c.  #9 
d.  #10 
e.  #11 

14.  Label the following parts of a nursing diagnosis statement: 
A.  Altered mobility _____________________ 
B.  related to weakness ___________________ 
C.  as evidenced by inability to ambulate independently   _______________________ 

15.  T or F  A high risk nursing diagnosis does not have 3 parts. 
 

16.  T or F  A nursing diagnosis of altered nutrition, less than body requirements would have a greater priority than  the diagnosis high risk for falls related to weakness. 

17.  What’s wrong with the following goal?  Rewrite it correctly 
 Understands how to do range of motion exercises and does them 50 times every hour. 
 

18.  Which of the following is a dependent nursing intervention? 
a.  Aspirin 80 mg Q AM 
b.  turn client every 2 hours 
c.  provide time for client to verbalize fears 
d.  teach client how to conserve strength during morning care 

Click on Answers to check your test results 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

ANSWERS 

1.  F 
2.  E 
3.  A 
4.  D 
5.  C 
6.  C 
7.  B 
8.  D 
9.  C 
10.  D 
11.  D 
12.  E 
13.  E 
14.  A- problem or title 
B-  Etiology 
C-  Defining Characteristics or sign and symptoms 
15.  T only problem and etiology or risk factors 
16.  T survival needs before safety 
17.  It is not measurable; it is unrealistic; it contains 2 goals in one statement; it has no deadline; it has no criteria for performance 
       Demonstrates ROM exercises independently according to written guidelines by tomorrow at 12:00 pm 
       Performs ROM exercises independently according to written guidelines BID every day until discharge. 
18. A 
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