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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Related Questions
Correct Answer is D
Explanation
Choice D rationale
Scheduling frequent rest periods can help manage the fatigue and concentration problems reported by the client. These symptoms are common in clients with CKD and elevated BUN and serum creatinine levels.
Choice A rationale
Administering PRN oxygen may not be necessary unless the client is showing signs of respiratory distress or hypoxia. There is no indication of this in the question.
Choice B rationale
Providing high protein snacks is not recommended for clients with CKD. High protein diets can increase the workload on the kidneys and worsen kidney function.
Choice C rationale
Monitoring glucose levels every 4 hours is not directly related to the client’s reported symptoms or the elevated BUN and serum creatinine levels.
Correct Answer is []
Explanation
Correct Actions:
Administer calcium as prescribed - Administering calcium (usually IV calcium gluconate) corrects the calcium deficiency, stabilizes nerve and muscle function, and helps stop or prevent further seizures.
Monitor respiratory status - Monitoring respiratory rate, effort, and oxygen saturation ensures early detection of hypoventilation, apnea, or oxygen desaturation.Maintaining airway and oxygenation is critical for safety and preventing hypoxia.
Correct Condition:
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.
Correct Parameters to monitor:
Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure.
Monitor serum calcium levels - Maintaining calcium within the normal neonatal range prevents recurrent seizures, cardiac arrhythmias, or neuromuscular irritability.
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