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 ["A","B","C","D","E"]

Explanation

- A) Knowing the medications the patient takes is crucial for understanding her medical history and any potential interactions with treatments that may be administered.

- B) Understanding the events leading up to the fall can help in assessing the cause and potential injuries sustained, which is important for her current and future treatment plans.

- C) Information about the last meal is important for anesthesia considerations, in case surgery is required, and for understanding the patient's nutritional status.
- D) Knowing if the patient is pregnant is vital as it influences the management of her care and the urgency of certain tests, as well as the avoidance of potential harm to the fetus.
- E) Information about cohabitants can be useful for social support and may also provide additional information about the circumstances leading to the injury.
- F) While insurance status is a practical consideration, it is not clinically relevant to the secondary survey and immediate care of the patient. Therefore, it is not an appropriate question at this stage.

A. Decreased hemoglobin and hematocrit levels B. Uptake often impeded by medications C. Often associated with chronic alcoholism D. Can be caused by malabsorption syndrome E. Result of dietary deficiency

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B,C"},"E":{"answers":"A,B,C"}}

Explanation

- Decreased hemoglobin and hematocrit levels: Consistent with iron deficiency anemia, vitamin B12 deficient anemia, and folic acid deficient anemia. Iron deficiency anemia results from
inadequate iron stores, while vitamin B12 deficient anemia and folic acid deficient anemia are characterized by inadequate levels of these respective vitamins, all of which contribute to decreased hemoglobin and hematocrit levels.
- Uptake often impeded by medications: Consistent with iron deficiency anemia and vitamin B12 deficient anemia. Iron absorption can be affected by certain medications, such as proton pump
inhibitors or antacids, which can hinder iron uptake. Vitamin B12 deficiency can result from medications that interfere with its absorption, such as proton pump inhibitors or metformin.

- Often associated with chronic alcoholism: Consistent with vitamin B12 deficient anemia. Chronic alcoholism can lead to vitamin B12 deficiency due to poor dietary intake,
malabsorption, or liver dysfunction associated with excessive alcohol consumption.

- Can be caused by malabsorption syndrome: Consistent with vitamin B12 deficient anemia and folic acid deficient anemia. Malabsorption syndromes, such as celiac disease or Crohn's disease, can impair the absorption of both vitamin B12 and folic acid from the gastrointestinal tract,
leading to deficiencies.

- Result of dietary deficiency: Consistent with iron deficiency anemia, vitamin B12 deficient anemia, and folic acid deficient anemia. Iron deficiency anemia results from inadequate dietary intake of iron-rich foods, while vitamin B12 deficient anemia and folic acid deficient anemia stem from insufficient dietary intake of foods rich in these respective vitamins.

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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

Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

Correct Answer is ["A","B","C","D","E"]

Explanation

Exhibits For each statement, click to specify whether the statement is consistent with iron deficiency anemia, vitamin B12 deficient anemia, or folic acid deficient anemia. Each row must have at least one, but may have more than one, response option selected.

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B,C"},"E":{"answers":"A,B,C"}}

Explanation

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which information reported by the client indicates understanding?

After receiving report, the nurse can most safely plan to assess which client last?

The nurse observes a client with amyotrophic lateral sclerosis (ALS) is excessively drooling and prepares to suction the client's oral cavity. Which action should the nurse include?

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?