An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?
Encourage the client to lie as still as possible during the assessment.
Question the client about the frequency of falls in recent months.
Assist the client with values clarification about end-of-life care options.
Ask the client how often episodes of sundowning are experienced.
The Correct Answer is B
A functional assessment is an evaluation of an individual's ability to perform activities of daily living (ADLs), which includes tasks such as bathing, dressing, toileting, eating, and mobility. Falls are a common and significant issue among older adults and are a leading cause of injury and hospitalization. Therefore, it is important to assess the client's risk of falling and inquire about any recent falls to develop an appropriate plan of care to prevent falls.
Encouraging the client to lie as still as possible during the assessment is not appropriate as it may not provide an accurate evaluation of the client's ability to perform ADLs.
Additionally, it is important to assess the client's functional status in a way that is safe and comfortable for them.
Assisting the client with values clarification about end-of-life care options is not appropriate during a functional assessment as it is not directly related to the client's ability to perform ADLs.
Asking the client how often episodes of sundowning are experienced is not appropriate during a functional assessment as sundowning is a symptom of dementia and is not directly related to the client's ability to perform ADLs.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","F"]
Explanation
A.Correct- The nurse should provide the parents with the phone numbers and websites of local organizations that offer support and counseling for families who have experienced a traumatic event. The nurse should also encourage the parents to seek professional help if they feel overwhelmed, depressed, or anxious.
B.Correct- Educating the parents about pool safety is crucial to prevent future accidents. This information can include guidelines for supervision, barriers, and measures to prevent drowning incidents.
C.Incorrect- While it's important for parents to be aware of the seriousness of child neglect, including this information in pre-discharge education might not be the most appropriate time, especially if the child is showing only minor signs of impact from the incident. This could increase their guilt and distress and damage the therapeutic relationship. The nurse should focus on providing support and education, not judgment or punishment.
D.Correct- The nurse should advise the parents to schedule a follow-up visit with the child's pediatrician within a week of discharge. The nurse should explain that the pediatrician will monitor the child's recovery and check for any signs of complications, such as brain damage, infection, or lung injury.
F. Correct- Assessing the parent's coping skills can help identify if they are dealing with any emotional stress or trauma related to the incident. Providing appropriate support or referrals if needed can be beneficial.
Correct Answer is D
Explanation
A) Incorrect- Dullness bilaterally on percussion is not a normal finding, but it is not an immediate concern after thoracentesis. It may indicate fluid accumulation or consolidation in both lungs, which could be related to other conditions such as pneumonia or heart failure.
B) Incorrect- Serosanguinous drainage from the chest tube is expected after thoracentesis, as long as it is not excessive or continuous. The nurse should monitor the amount and color of the drainage and document it accordingly.
C) Incorrect- Diminished breath sounds in the left lower lobe are also expected after thoracentesis, as the procedure removes fluid and air from the pleural space and reduces lung expansion. The nurse should auscultate the lungs before and after the procedure and compare the findings. The breath sounds should improve gradually as the lung re-expands.
D) Correct- This is a sign of tension pneumothorax, which is a life-threatening complication of thoracentesis. Tension pneumothorax occurs when air accumulates in the pleural space and creates positive pressure that pushes the mediastinum (the heart, great vessels, and trachea) to the opposite side of the chest. This can impair venous return, cardiac output, and respiratory function. The nurse should report this finding to the healthcare provider immediately and prepare to assist with needle decompression or chest tube insertion.
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