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 ["C","D","E"]
Explanation
Choice A reason: Standard precautions are always used, but a mask is not specifically required unless performing a procedure that risks splashing. MRSA is primarily spread through direct contact, so masks are not the main precaution for this client.
Choice B reason: A low bacteria diet is not typically required for MRSA or osteomyelitis management and does not directly impact the treatment or prevention of infection spread.
Choice C reason: Contact precautions are critical for preventing MRSA transmission, as it can be spread by direct contact with the infected wound or contaminated surfaces.
Choice D reason: Sending wound drainage for culture and sensitivity is crucial to identify the specific strain of MRSA and determine the most effective antibiotic treatment.
Choice E reason: Monitoring the white blood cell count is important to assess the body's response to infection and the effectiveness of treatment.
Correct Answer is B
Explanation
Choice A reason: A blood pressure of 130/80 mm Hg is considered high normal and may not require immediate follow-up for a patient with a history of hypertension.
Choice B reason: A serum creatinine of 1.6 mg/dL is above the normal range for both males and females, indicating possible kidney dysfunction, which requires further follow-up.
Choice C reason: Dark yellow urine could be a sign of dehydration, which is common in diabetes, but it is not as concerning as an elevated serum creatinine level.
Choice D reason: Difficulty staying asleep could be related to various factors and may require follow-up, but it is not as urgent as abnormal laboratory values.
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