An older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

Inquire about the frequency of falls in recent months.

Ask the patient how often episodes of sundowning are experienced.

Assist the patient with clarifying values about end-of-life care options.

Request the patient to lie as still as possible for the assessment.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Inquiring about the frequency of falls in recent months is an important part of a functional assessment for an older adult patient reporting decreased strength in knees and handgrips. Falls can be a sign of decreased muscle strength and balance, which can be associated with aging and certain medical conditions.

Choice B rationale

Sundowning, or increased confusion and agitation in the late afternoon and evening, is a symptom often associated with dementia, not necessarily with decreased strength in knees and handgrips.

Choice C rationale

While discussing end-of-life care options is an important aspect of comprehensive patient care, it is not directly related to the patient’s reported symptoms of decreased strength.

Choice D rationale

Requesting the patient to lie as still as possible for the assessment may not provide comprehensive information about the patient’s functional mobility and strength.

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Correct Answer is ["A","F"]

Explanation

Choice A rationale

Stabilizing the cervical spine is one of the first actions that should be taken during the primary survey of a trauma patient. This is to prevent any potential injury to the spinal cord, which could result in permanent paralysis.

Choice B rationale
Checking for a pulse is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice C rationale
Requesting an x-ray is not one of the first actions that should be taken during the primary survey. The first priority is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.

Choice D rationale
Assessing the respiratory rate is an important part of the primary survey, but it is not one of the first actions that should be taken. The first priority is to ensure that the airway is patent and the cervical spine is stabilized.

Choice E rationale
Examining the abdomen is an important part of the secondary survey, which is conducted after the primary survey. The first priority during the primary survey is to assess the client’s airway, breathing, and circulation, and to stabilize the cervical spine.
Choice F rationale

Ensuring that the airway is patent is one of the first actions that should be taken during the primary survey. This is to ensure that the client is able to breathe effectively and receive adequate oxygenation.

A. Monitor the client’s white blood cell count. B. Implement contact precautions for staff and visitors. C. Use standard precautions and wear a mask. D. Explain the purpose of a low bacteria diet. E. Send wound drainage for culture and sensitivity.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale

Monitoring the client’s white blood cell count is important in this case. An elevated white blood cell count is a common sign of infection, and regular monitoring can help assess the client’s response to treatment.
Choice B rationale
Implementing contact precautions for staff and visitors is crucial when caring for a client with a potential VRE infection. VRE is a multi-drug resistant organism that can be spread through direct contact, so strict infection control measures are necessary.
Choice C rationale
Using standard precautions and wearing a mask is generally good practice in healthcare settings to prevent the spread of infections. However, a mask is not specifically required for contact precautions with VRE456.
Choice D rationale
Explaining the purpose of a low bacteria diet is not relevant in this case. While diet can play a role in overall health and recovery, it is not a specific intervention for a client with a potential VRE infection.
Choice E rationale
Sending wound drainage for culture and sensitivity is an important step in confirming the presence of VRE and determining the most effective antibiotic therapy.

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An older adult patient arrives at the clinic reporting decreased strength in knees and handgrips. What action should the nurse include in a functional assessment of this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client is a 26-year-old female who fell from an apartment balcony. She was transported to the hospital via ambulance. The client enters the emergency room on a stretcher and is met in the trauma bay by the nurse. What two actions should the nurse take first during the primary survey?

Correct Answer is ["A","F"]

Explanation

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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