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 D

Explanation

Choice A rationale

While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations.

Choice B rationale

The timing of the voices can provide some insight into the triggers or patterns of the hallucinations, but it does not directly address the content or potential impact of the hallucinations on the client’s behavior or mental state.

Choice C rationale

While medication efficacy is an important aspect of managing schizophrenia, it does not directly address the current experience of the client’s hallucinations.

Choice D rationale

Understanding what the voices are saying to the client can provide critical information about potential risks, including self-harm or harm to others, and can guide the treatment plan. This is why it is the most important question for the nurse to include in the client’s assessment.

A. Reassure that this can be a normal post-surgical sensation. B. Guide in moving the unaffected limb to override the sensation being experienced. C. Explain that the sensations of tingling and pain are not real. D. Affirm that a prosthetic with physical therapy will gradually improve the symptoms.

Correct Answer is D

Explanation

Choice A rationale
While it’s true that phantom limb pain can be a normal post-surgical sensation, simply reassuring the patient doesn’t address the pain they’re experiencing.
Choice B rationale
Guiding in moving the unaffected limb to override the sensation being experienced is not a recommended intervention for phantom limb pain. Phantom limb pain is a complex phenomenon that is not simply overridden by movement of other body parts.

Choice C rationale
Explaining that the sensations of tingling and pain are not real may invalidate the patient’s experience. Phantom limb pain is a real phenomenon experienced by many amputees. It’s not just a sensation; it’s a type of neuropathic pain that can be severe and debilitating.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is the best non-pharmacological intervention among the choices. Physical therapy, including mirror therapy and other desensitization techniques, can help manage phantom limb pain. The use of a prosthetic can help the patient regain function and mobility, which can also improve their overall well-being and potentially reduce the perception of phantom limb pain.

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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

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

Correct Answer is D

Explanation

The nurse is providing postoperative care for an adolescent who had a left leg amputation due to osteosarcoma and is experiencing phantom limb pain. What non-pharmacological intervention should the nurse provide?

Correct Answer is D

Explanation

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