An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?
Assist the client with clarifying values about end-of-life care options.
Ask the client how often episodes of sundowning are experienced.
Request to have the client lie as still as possible for the assessment.
Question the client about the frequency of falls in recent months.
The Correct Answer is D
A. This action pertains more to discussions about advance care planning and end-of-life preferences, which may be important but are not directly related to assessing the client's functional status.
B. Episodes of sundowning are associated with changes in behavior, confusion, and agitation in some individuals with dementia, particularly in the late afternoon or evening. While important to assess in certain contexts, it is not directly related to evaluating the client's physical strength and mobility.
C. Asking the client to lie still does not provide information about their functional status or ability to perform activities of daily living.
D. This is the most appropriate action because it directly addresses the client's reported decreased strength and assesses the impact on their functional ability. Falls are a common consequence of reduced strength and mobility in older adults and can provide valuable information about the client's current physical function and safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Gained 10 lb (4.5 kg) within one month. Weight gain is not typically associated with the onset of type 1 diabetes. In fact, weight loss is more common due to the body's inability to use glucose properly.
B. Drinks more fluids than previously. Increased thirst (polydipsia) is a classic symptom of type 1 diabetes due to high blood sugar levels causing dehydration.
C. Voids only one or two times per day. Increased urination (polyuria) is a common symptom of type 1 diabetes as the body attempts to excrete excess glucose, so decreased urination is unlikely.
D. Refuses to eat favorite meals at home. While changes in appetite can occur, it is not a primary symptom of type 1 diabetes. Increased hunger (polyphagia) is more typical.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Semi Fowler's position:
- This position involves raising the head of the bed to an angle of 30 to 45 degrees. It is
commonly used to improve respiratory function and comfort in patients who are experiencing
difficulty breathing. By elevating the head and torso, this position facilitates better lung expansion, helping to improve oxygenation.
Promote lung expansion:
- In patients with respiratory issues such as pneumonia, positioning that enhances lung expansion is critical. Semi Fowler's position helps to reduce pressure on the diaphragm, allowing for more effective lung expansion and improved oxygenation. This is particularly important for a patient with decreased breath sounds and consolidation in the lungs, as it aids in alleviating respiratory distress and improving gas exchange.
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