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 B

Explanation

Choice A rationale
Using an electric heating pad when the pain is at its worst is not recommended for a client with gout. Heat can increase inflammation and exacerbate pain. Instead, applying a cold pack to the inflamed joint can help reduce inflammation and relieve pain.
Choice B rationale
Acetylsalicylic acid, also known as aspirin, can increase uric acid levels in the blood and exacerbate gout symptoms. Therefore, clients with gout should avoid taking medications containing acetylsalicylic acid.
Choice C rationale
Consuming high-protein foods can increase uric acid levels in the blood and trigger a gout attack. Clients with gout are usually advised to follow a low-purine diet, which involves limiting the intake of high-purine foods such as red meat and seafood.

Choice D rationale
Encouraging active range of motion to limit stiffness may not be appropriate for a client with an acute gout attack. During an attack, moving the affected joint can be extremely painful. Rest and immobilization of the affected joint are usually recommended during this time.

A. Encourage the client to participate in a team sport for one hour. B. Assist the client in developing a list of daily affirmations. C. Schedule the client for a group session that focuses on self-esteem. D. Help the client in identifying goals for the day.

Correct Answer is D

Explanation

Choice A rationale

Encouraging the client to participate in a team sport for one hour might be beneficial for the client’s physical health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice B rationale
Assisting the client in developing a list of daily affirmations can be a helpful strategy for improving self-esteem and promoting positive thinking, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice C rationale
Scheduling the client for a group session that focuses on self-esteem can be beneficial for the client’s mental health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice D rationale
Helping the client in identifying goals for the day can be a very effective intervention for a client with severe depression. Setting daily goals can provide the client with a sense of purpose and can help to motivate the client to engage in activities other than sitting and watching television.

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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

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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