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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: While assessing breath sounds is part of a comprehensive evaluation, it is not the most critical intervention for a TIA, which primarily affects neurological function.

Choice B reason: Palpating the suprapubic region for urinary retention is important but not the priority intervention for a client with TIA, as it does not directly relate to the risk of stroke.

Choice C reason: Reviewing the client's daily medications is necessary for overall care but is not the most immediate concern upon admission for a TIA.

Choice D reason: Initiating neurological monitoring every 2 hours is essential for a client with TIA to promptly identify any changes or progression in neurological status, which could indicate a stroke. This is the most important intervention to include in the plan of care for a client admitted with TIA. Neurological monitoring allows for immediate intervention if the client's condition worsens, potentially preventing further ischemic damage.

A. Application of heat and cold therapy. B. Avoidance of foods containing purine. C. Immobilization of affected joints. D. Prevention through nutrition and exercise.

Correct Answer is D

Explanation

Choice A reason: Application of heat and cold therapy can help manage symptoms but does not encompass the broader aspects of health promotion and teaching.

Choice B reason: Avoidance of foods containing purine is more specific to conditions like gout rather than rheumatoid arthritis, and while diet is important, it does not fully represent health promotion and teaching.

Choice C reason: Immobilization of affected joints is not a health promotion strategy and can actually worsen symptoms over time. Active and passive range-of-motion exercises are recommended instead.

Choice D reason: Prevention through nutrition and exercise is the most comprehensive approach that aligns with health promotion and teaching for clients with rheumatoid arthritis. It includes educating clients on a balanced diet and physical activity to manage symptoms and improve overall health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care?

Correct Answer is D

Explanation

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis?

Correct Answer is D

Explanation

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Patient Data Exhibits Review H and P and laboratory results. Drag from the Word Choices to complete the sentence. For the nutrition education portion of the visit, the nurse focuses on dropdown and dropdown.

Patient Data Exhibits Review H and P, nurse's note, and laboratory results. Click to mark whether the client statement indicates understanding no understanding of the education given.