Week 4 Matrix Questions

Match each neurologic finding or need with the most appropriate assessment tool. Select the correct tool for each patient situation.

Client post-head injury, eye opening and motor response being tracked
Client demonstrating confusion with date, place, and memory
Client evaluated for balance with feet together, eyes closed
Client recovering from stroke with delayed verbal response


Glasgow Coma Scale
Mini-Mental Exam
Romberg Test

Client post-head injury, eye opening and motor response being tracked → Glasgow Coma Scale

Client demonstrating confusion with date, place, and memory → Mini-Mental Exam

Client evaluated for balance with feet together, eyes closed → Romberg Test

Client recovering from stroke with delayed verbal response → Glasgow Coma Scale

You are creating care plans for immobile clients. Select which intervention is most effective for preventing the listed complication.

Pressure injury in an elderly bedbound client
Lower extremity muscle wasting
Postoperative DVT formation
Joint contracture in a paralyzed limb



Active ROM
Frequent Repositioning
Sequential Compression Devices (SCDs)

Complication	Answer (Intervention)	Rationale
Pressure injury in an elderly bedbound client	Frequent Repositioning	Frequent turning alleviates pressure on skin, reducing ischemia risk.
Lower extremity muscle wasting	Active ROM	Prevents disuse atrophy and maintains strength/mass.
Postoperative DVT formation	Sequential Compression Devices (SCDs)	SCDs promote venous return to prevent clot formation.
Joint contracture in a paralyzed limb	Active ROM	Keeps joints mobile and prevents flexion fixation.

Match each clinical observation to the most likely musculoskeletal condition. Choose from Fracture, Arthritis, Muscle Atrophy.

Decreased strength, soft boggy muscle on left leg
Pain and stiffness in joints, especially in the morning
Sharp pain and swelling after a fall on the hip
Difficulty rising from a chair without assistance

Decreased strength, soft boggy muscle on left leg → Muscle Atrophy

Pain and stiffness in joints, especially in the morning → Arthritis

Sharp pain and swelling after a fall on the hip → Fracture

Difficulty rising from a chair without assistance → Muscle Atrophy

A nurse is reviewing a care plan for four clients with varying degrees of immobility. Select which intervention best matches the complication it is designed to prevent.


Contracture development in a bedbound client
Pressure injury on sacrum in an incontinent client
Deep vein thrombosis in a post-op client
Muscle atrophy in an immobilized client

Prevented by ROM
Prevented by Repositioning
Prevented by Compression Devices

Contracture development in a bedbound client → Prevented by ROM

Pressure injury on sacrum in an incontinent client → Prevented by Repositioning

Deep vein thrombosis in a post-op client → Prevented by Compression Devices

Muscle atrophy in an immobilized client → Prevented by ROM

A nurse is reviewing documentation from clients with altered sensory input. Select whether each client case reflects Vision Loss, Hearing Loss, or Cognitive Impairment.

Client Description	Answer	Rationale

Bumps into corners and squints in bright light

Vision Loss

Signs of impaired visual acuity, depth perception, or light sensitivity (e.g., cataracts, macular degeneration).

Repeats “What?” and turns head toward speaker

Hearing Loss

Classic compensatory behavior in hearing loss, especially sensorineural type.

Forgets room layout, staff names repeatedly

Cognitive Impairment

Disorientation and memory gaps point to neurologic or cognitive deficits (e.g., dementia).

Avoids outdoors due to light discomfort

Vision Loss

Light sensitivity + avoidance indicates possible vision impairment.

You are reviewing daily care priorities for a group of older adult clients. Select whether the nurse should focus on Safety, Communication, or Independence.

Client with uncorrected vision impairment and poor lighting at home
Client with moderate expressive aphasia post-stroke
Client asking to dress himself using adaptive equipment
Client with dizziness and history of falls


Client with uncorrected vision impairment and poor lighting at home → Safety

Client with moderate expressive aphasia post-stroke → Communication

Client asking to dress himself using adaptive equipment → Independence

Client with dizziness and history of falls → Safety