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.

Answer and Explanation

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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Correct Answer is A

Explanation

Regular weighing is an essential self-management strategy for clients with heart failure (HF). It helps monitor changes in fluid balance, which is crucial in managing HF symptoms. Sudden weight gain may indicate fluid retention, a worsening of HF, or the need for adjustments in medications or dietary restrictions. Daily weighing provides valuable information for both the client and healthcare provider to assess the effectiveness of the HF management plan.

While performing range of motion exercises and maintaining mobility are important for overall health, they may not be specifically related to the management of heart failure. The focus of discharge teaching for HF is typically on monitoring symptoms, medication management, diet and fluid restrictions, and when to seek medical attention.

Limiting fluid intake to 1,500 mL daily may be a general recommendation for some clients with HF, but it is best to individualize fluid restrictions based on the client's specific needs. The client should follow the fluid restriction prescribed by their healthcare provider, which may vary depending on the severity of HF and other individual factors.

While maintaining a balanced diet, including adequate protein intake, is important for overall health, there may be specific dietary recommendations for clients with HF that go beyond a general instruction to eat a high protein diet. Dietary instructions for HF clients typically include sodium restriction, fluid restriction if necessary, and considerations for comorbidities and medications.

A. Remove electrodes and observe for skin redness. B. Decrease the strength of the electrical signals. C. Check the amount of gel coating on the electrodes. D. Determine if the sensation feels uncomfortable.

Correct Answer is D

Explanation

A) Incorrect - Skin redness might indicate irritation, but the initial focus should be on the client's sensation.
B) Incorrect - Decreasing the strength of the electrical signals might be premature if the sensation is normal.
C) Incorrect - The amount of gel coating on the electrodes might not be the primary issue if the client is feeling a tingling sensation.
D) Correct- A tingling sensation is normal and expected when using a TENS unit, and it does not indicate any harm or damage to the skin or nerves. However, the sensation should not be painful or unpleasant for the client, and the nurse should adjust the intensity of the electrical signals accordingly.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan?

Correct Answer is A

Explanation

A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Correct Answer is D

Explanation

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