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 ["100"]
Explanation
- Total volume of the infusion: 50 mL (saline bag)
- Infusion time: 30 minutes = 0.5 hours (convert minutes to hours)
- We don't need the concentration of gentamicin for this calculation because we're only interested in the total volume delivered per hour.
- Flow rate: Since all the medication is delivered within the infusion time, the flow rate is equal to the total volume divided by the infusion time.
Flow rate (mL/hour) = Total volume (mL) / Infusion time (hours)
Flow rate = 50 mL / 0.5 hours Flow rate = 100.0 mL/hour
Therefore, the nurse should set the pump to deliver 100.0 mL/hour to infuse the 60 mg of gentamicin over 30 minutes.
Correct Answer is D
Explanation
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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