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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While repeated requests for attention from the nurse might indicate distress, they are not necessarily indicative of potential aggression or disruptive behavior.
B. Periodic sighing and shaking the head could suggest the client's emotional state, but they are not as indicative of potential aggression or disruptive behavior as argumentativeness and profanity.
C. Monitoring for argumentativeness and the use of profanity is crucial as they can escalate into disruptive or potentially aggressive behavior. It's important to assess the client's agitation level and ensure the safety of both the client and others on the mental health unit.

D. Decreased activity level and a change in affect may suggest a worsening of the client's mental state but are not immediate concerns in terms of safety on the unit.

A. Collaborate with a science teacher to prepare a health lesson. B. Initiate a hearing and vision screening program for first graders. C. Prepare a presentation on how to prevent the spread of lice. D. Observe a person with type 1 diabetes mellitus self-administer a dose of insulin.

Correct Answer is B

Explanation

A. Collaborating with a science teacher to prepare a health lesson may be beneficial for health education but does not directly address secondary prevention. Secondary prevention involves early detection and intervention to prevent the progression of disease or injury.

B. Initiating a hearing and vision screening program for first graders is an example of secondary prevention. This action aims to detect any hearing or vision problems early, allowing for timely intervention and management to prevent further complications or difficulties in learning and
development.

C. Preparing a presentation on how to prevent the spread of lice may be important for promoting hygiene and preventing infestations, but it falls more under the category of health education and primary prevention rather than secondary prevention.

D. Observing a person with type 1 diabetes mellitus self-administer a dose of insulin may be related to health education or management of a chronic condition, but it does not directly address secondary prevention for school-aged children.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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