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 D
Explanation
Choice A reason: Heat and cold therapy can help manage symptoms but are not directly related to health promotion and teaching.
Choice B reason: Avoiding foods containing purine is more related to conditions like gout, not rheumatoid arthritis.
Choice C reason: Immobilization of affected joints is not a health promotion strategy and can actually worsen rheumatoid arthritis symptoms over time.
Choice D reason: Prevention through nutrition and exercise is a key component of health promotion and teaching for clients with rheumatoid arthritis, as it can help manage symptoms and improve overall health.
Correct Answer is ["2.4"]
Explanation
Step 1: Convert the weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, the weight in kg is:
175 lbs ÷ 2.2 = 79.55 kg
Step 2: Calculate the total units of heparin needed. The prescription is for 3 units/kg, so:
3 units/kg × 79.55 kg = 238.65 units
Step 3: Calculate the volume of heparin to administer. The vial is labeled as "100 units/mL", so:
238.65 units ÷ 100 units/mL = 2.39 mL
So, the nurse should administer approximately 2.4 mL of heparin (rounded to the nearest tenth).
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