An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?
Encourage the client to lie as still as possible during the assessment.
Ask the client how often episodes of sundowning are experienced.
Assist the client with values clarification about end-of-life care options.
Question the client about the frequency of falls in recent months.
The Correct Answer is D
Choice A reason: Encouraging the client to lie still during the assessment is not advisable as it does not provide an accurate representation of the client's functional abilities and needs during rehabilitation.
Choice B reason: While understanding episodes of sundowning can be part of a comprehensive assessment, it is not the action the nurse should implement during a functional assessment aimed at determining the client's physical capabilities.
Choice C reason: Assisting with values clarification about end-of-life care options is important but is not the primary focus of a functional assessment in a rehabilitation setting.
Choice D reason: Questioning the client about the frequency of falls is crucial as it helps assess the risk of future falls and the need for interventions to prevent them, which is a key component of functional assessments in rehabilitation settings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Choice A Reason: Selecting only food items with no fat is not recommended because some fats, particularly unsaturated fats, are beneficial for health and should be included in a balanced diet.
Choice B Reason: Taking a cinnamon supplement may be beneficial as some studies suggest that cinnamon can help lower blood sugar levels and improve insulin sensitivity.
Choice C Reason: Minimizing the number of refined grains in the diet is advised because refined grains can have a negative impact on blood sugar control and may increase the risk of type 2 diabetes.
Choice D Reason: Eliminating sugary beverages and juices from the diet is beneficial as these can lead to spikes in blood sugar levels and contribute to weight gain, which is a risk factor for type 2 diabetes.
Choice E Reason: Doubling the usual amount of protein in the diet is not necessary and could lead to an excessive intake of calories. Protein should be consumed in moderation and as part of a balanced diet.
Choice F Reason: Increasing the amount of dietary fiber is recommended because fiber can help manage blood sugar levels and reduce the risk of developing type 2 diabetes.
Correct Answer is B
Explanation
Choice A reason: Washing hands for a total of 20 seconds is recommended by the CDC as part of proper hand hygiene to prevent the spread of germs.
Choice B reason: Turning the water off using bare hands after washing can re-contaminate the hands. The CDC recommends using a paper towel to turn off the tap to avoid re-contamination.
Choice C reason: Keeping hands below elbows when rinsing is the correct procedure to prevent water from running down the arms onto the cleaned hands.
Choice D reason: Lathering using a circular movement is a recommended technique to ensure all surfaces of the hands are cleaned thoroughly.
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