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
Explanation
Choice A reason: Assessing body temperature is a routine post-procedure check but not the most critical for thrombocytopenia.
Choice B reason: Monitoring skin elasticity is not directly related to the risks associated with thrombocytopenia following a bone marrow biopsy.
Choice C reason: Observing the aspiration site is crucial because thrombocytopenia increases the risk of bleeding, and the site must be monitored for any signs of hemorrhage.
Choice D reason: Measuring urinary output is important but does not take precedence over monitoring the biopsy site for bleeding in a thrombocytopenic patient.
Correct Answer is C
Explanation
Choice A reason: Offering supplemental formula feedings is not the first-line action for inverted nipples as it does not address the issue and may lead to nipple confusion, potentially complicating future breastfeeding attempts.
Choice B reason: Teaching about the use of a breast pump is beneficial for milk expression but does not directly assist with the immediate concern of latching issues due to inverted nipples.
Choice C reason: Using a breast shield can be helpful for mothers with inverted nipples. It can temporarily draw out the nipple, allowing the baby to latch on more easily. This tool acts as a bridge between the breast and the baby's mouth, facilitating breastfeeding while the mother works on long-term solutions for her inverted nipples.
Choice D reason: Encouraging the use of ice on the areola may temporarily stiffen the nipple, but it is not a recommended practice for addressing inverted nipples as it can cause discomfort and may not be effective in promoting a successful latch.
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