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 []

Explanation

Actions to Take:

A. Educate on disease process and management: Rheumatoid arthritis (RA) is a chronic

autoimmune disorder characterized by inflammation of the synovial membrane, leading to joint pain, swelling, and stiffness. Educating the client about RA helps them understand the disease, its

progression, treatment options, and the importance of adherence to prescribed medications and lifestyle modifications. This empowers the client to actively participate in managing their condition and improve outcomes.

B. Turn every two hours to offload bony prominences to prevent pressure injuries: Rheumatoid arthritis predisposes individuals to joint deformities and immobility due to joint inflammation and pain. Immobility increases the risk of pressure injuries, especially over bony prominences. Turning the client every two hours helps redistribute pressure, reduces the risk of pressure ulcers, and maintains skin integrity.

Potential Condition:

D. Rheumatoid arthritis: The client's clinical presentation, including bilateral joint pain and stiffness, positive rheumatoid factor, positive antinuclear antibody test, elevated erythrocyte sedimentation rate (ESR), and soft tissue swelling with marginal erosions on hand X-rays, is consistent with rheumatoid arthritis (RA). RA is a chronic autoimmune disease characterized by inflammation of the synovial joints, leading to joint damage, pain, and functional impairment.

Parameters to Monitor:

C. Pain: Monitoring pain is essential in rheumatoid arthritis management to assess the effectiveness of pain management interventions and adjust treatment accordingly. Pain assessment tools, such as numerical rating scales or visual analog scales, help quantify pain intensity and guide pain management strategies.

D. Skin breakdown: Rheumatoid arthritis can limit mobility and predispose individuals to prolonged immobility, increasing the risk of pressure injuries. Monitoring for signs of skin breakdown, such as erythema, blanchable or non-blanchable skin changes, and skin integrity over bony prominences, helps prevent pressure ulcers and facilitates early intervention if skin breakdown occurs. Regularly turning the client, maintaining proper positioning, and providing adequate support surfaces are essential to prevent pressure injuries.

A. Respiratory acidosis. B. Respiratory alkalosis. C. Metabolic acidosis. D. Metabolic alkalosis.

Correct Answer is B

Explanation

A. Respiratory acidosis. Respiratory acidosis occurs when there is hypoventilation, leading to an accumulation of carbon dioxide and increased acidity in the blood. Hyperventilation, as described in the scenario, would not lead to respiratory acidosis.
B. Respiratory alkalosis. Hyperventilation leads to respiratory alkalosis by blowing off excessive carbon dioxide, resulting in decreased levels of carbonic acid and increased blood pH.
C. Metabolic acidosis. Metabolic acidosis results from an accumulation of acids or loss of bicarbonate ions. The scenario does not indicate factors leading to metabolic acidosis.
D. Metabolic alkalosis. Metabolic alkalosis occurs due to excessive loss of acids or increased bicarbonate levels, neither of which is suggested in the scenario.

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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 Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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Correct Answer is B

Explanation

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