A nurse is caring for an 84-year-old female client in her home following an investigation by Adult Protective Services.
Drag from the statement options to complete the sentence.
To assess outcomes, the nurse should consider information reported by the client and caregiver and focus on evaluating the client’s:
Psychological assessment
Financial security
Quality of life
Functional improvement
The Correct Answer is D
Choice A rationale: While psychological assessment is important, it is not the primary focus for assessing outcomes in this case. The client's physical health conditions and the impact on her daily living and functional ability are more directly relevant.
Choice B rationale: Financial security is not the primary concern in this context. The primary focus is on the client's health and ability to perform activities of daily living (ADLs), which is addressed by evaluating functional improvement.
Choice C rationale: Quality of life is a broad concept that includes many aspects such as emotional, social, and physical well-being. While it is relevant, the primary outcome measure in this context is the client's functional improvement related to her health conditions and ability to manage ADLs.
Choice D rationale: Functional improvement is the correct focus for evaluating the client's outcomes. This includes her ability to perform activities of daily living (ADLs) and manage her health conditions. The nurse should assess how well the client can maintain or improve her functional abilities with the additional care provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice B rationale: Capillary refill time of 6 seconds is significantly delayed and indicates poor peripheral perfusion. This finding suggests that the client may be experiencing decreased cardiac output or hypovolemia, which requires immediate attention to improve circulation and oxygen delivery to tissues.
Choice C rationale: Blood pressure of 90/79 mmHg with a pulse pressure of less than 40 mmHg is a critical finding. The narrow pulse pressure and hypotension indicate potential hypovolemia or shock, which must be addressed urgently to stabilize the client's hemodynamic status.
Choice D rationale: The client’s lack of urine output from the indwelling catheter is concerning and indicates potential kidney dysfunction or decreased renal perfusion. Immediate intervention is necessary to assess and manage potential underlying causes, such as hypovolemia or renal injury.
Choice A rationale: Oxygen saturation of 100% on 40% oxygen is not an immediate concern. While it is important to continue monitoring oxygen levels, the client is currently receiving adequate oxygenation.
Correct Answer is C
Explanation
Choice A rationale
Pedal edema is an assessment related to heart failure or peripheral vascular disease but is not specifically connected to the adverse effects of prasugrel, which is an antiplatelet medication that primarily affects blood clotting processes.
Choice B rationale
Measuring body temperature can help detect infections or fever, but it is not a primary assessment for the adverse effects of prasugrel. The medication's adverse effects are more closely related to bleeding risks.
Choice C rationale
Prasugrel, an antiplatelet medication, increases the risk of bleeding. Observing the color of urine can help detect hematuria, an indication of internal bleeding, making it a critical assessment for clients taking this medication.
Choice D rationale
Assessing skin turgor is generally used to evaluate hydration status, not to monitor for adverse effects of prasugrel. This assessment would not provide relevant information about bleeding risks associated with prasugrel use.
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