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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Allowing the client to express their feelings is an important part of providing psychosocial support. However, it does not specifically address the client’s need for acceptance.
Choice B rationale
Wearing gloves during the client interview can actually reinforce feelings of stigma and rejection, as it may suggest that the nurse is afraid of touching the client or catching their condition.
Choice C rationale
Offering a handshake during introductions can be a powerful gesture of acceptance, especially for a client with a visible skin condition like psoriasis. It communicates that the nurse is not afraid of physical contact and accepts the client as they are.
Choice D rationale
Encouraging the client to join a support group can provide them with a sense of community and shared experience, but it does not specifically address the client’s need for acceptance in their individual interactions with healthcare providers.
Correct Answer is B
Explanation
Choice A rationale
Gastric lavage is a procedure that involves the insertion of a tube into the stomach to remove its contents and is typically used in cases of poisoning or drug overdose. However, it should not be the first action taken. The type of chemical exposure needs to be determined first to guide appropriate treatment.
Choice B rationale
Determining the type of chemical exposure is crucial as it guides the subsequent steps in management. Different chemicals can have different effects on the body and require different treatments.
Choice C rationale
While assessing for altered sensorium is important in a child exposed to chemicals, it is not the first action. The nurse needs to identify the type of chemical the child was exposed to in order to anticipate potential complications and guide treatment.
Choice D rationale
Calling the poison control emergency number is an important step in managing a case of chemical exposure. However, having information about the type of chemical the child was exposed to can make this call more effective.
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