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 ["A","B","D","F"]
Explanation
Choice A reason: Walking frequently during recovery is essential for preventing blood clots, improving circulation, and aiding in the healing process. It is recommended for patients to start with short, frequent walks and gradually increase the distance as tolerated. This helps to enhance physical activity and supports weight loss maintenance post-surgery.
Choice B reason: After bariatric surgery, patients are typically started on a clear liquid diet and then advanced to full liquids before progressing to pureed foods and eventually solid foods. This gradual progression is necessary to allow the stomach to heal and to avoid complications such as leaks or obstructions at the surgical site.
Choice D reason: Patients who have undergone bariatric surgery are at risk for nutritional deficiencies due to the reduced intake and absorption of nutrients. Therefore, taking prescribed vitamin and mineral supplements is crucial to prevent deficiencies and ensure adequate nutrition.
Choice F reason: Starting with room temperature water can help prevent discomfort and gastrointestinal symptoms that may occur when drinking cold fluids after surgery. Room temperature fluids are generally better tolerated in the immediate postoperative period.
Choice C reason: While weight loss is expected after bariatric surgery, it is not accurate to anticipate that weight loss will continue with a normal diet. Patients must adhere to a specific postoperative diet and lifestyle changes to ensure continued weight loss and avoid weight regain.
Choice E reason: Ovulation and fertility can be affected by significant weight loss; however, it is not appropriate to expect an immediate return of ovulation post-surgery. Fertility changes can vary from person to person and may take time.
Choice G reason: Encouraging three large meals a day is contrary to the recommended dietary guidelines post-bariatric surgery. Patients are advised to eat small, frequent meals to accommodate the reduced stomach capacity and to prevent symptoms of dumping syndrome.
Choice H reason: Dietician appointments are not optional but are a critical component of postoperative care. Regular follow-up with a dietician ensures that patients receive personalized nutritional guidance and support as they adjust to their new dietary habits.
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