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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C: “This must be a very difficult time for you.”
Choice A rationale: Telling the parent “You didn’t do anything wrong” might seem comforting, but it doesn’t address the parent’s feelings of guilt or responsibility.It’s important to remember that myelomeningocele is a birth defect that occurs when the spine and spinal cord do not develop completely1.It’s often not known why this happens, but it can be due to a combination of genetic and environmental factors2. Therefore, it’s not something the parent did or didn’t do.
Choice B rationale: Asking “Is there any particular reason why you think this is your fault?” could potentially lead to a constructive conversation. However, it might also make the parent feel defensive or as if they need to justify their feelings. It’s crucial to approach this situation with empathy and understanding, acknowledging the parent’s feelings without making them feel judged.
Choice C rationale: Saying “This must be a very difficult time for you” is the most helpful response because it acknowledges the parent’s feelings and offers empathy. It doesn’t place blame or make assumptions. Instead, it opens up a space for the parent to express their feelings and concerns.
Choice D rationale: While it’s true that surgery can help manage the condition1, saying “With surgery, your baby should have a full recovery” might be misleading.Myelomeningocele is the most severe form of spina bifida and can cause moderate to severe disabilities, such as muscle weakness, loss of bladder or bowel control, and/or paralysis2. Each case is unique, and while some children may have less severe symptoms, others may require lifelong management. It’s important to provide accurate and realistic information.
Remember, it’s essential to approach these conversations with empathy and understanding. Parents dealing with a diagnosis of myelomeningocele are likely experiencing a range of emotions, and they need support and accurate information.
Correct Answer is C
Explanation
The property of the drugs that, if shared by both, indicates a need to closely monitor the client for drug toxicity is:
Highly protein bound.
When a drug is highly protein bound, it means that a significant portion of the drug molecules bind to proteins in the bloodstream. This binding can affect the availability and distribution of the drug in the body. If two drugs are highly protein bound and administered together, they may compete for binding sites on the proteins, leading to increased levels of unbound (free) drug in the bloodstream. This can result in higher drug concentrations and an increased risk of drug toxicity.
Closely monitoring the client for drug toxicity is necessary when drugs are highly protein bound because there is a potential for increased drug levels and associated adverse effects. Monitoring for signs and symptoms of drug toxicity, as well as routine laboratory tests to assess liver and kidney function, may be necessary in these cases.
The other properties listed do not necessarily indicate a need for closer monitoring for drug toxicity:
- Low bioavailability refers to the fraction of an administered dose that reaches the systemic circulation in an active form. While low bioavailability can affect the effectiveness of a drug, it does not directly imply a need for closer monitoring for drug toxicity.
- Short half-life refers to the time it takes for half of the drug concentration in the body to be eliminated. While drugs with short half-lives may require more frequent dosing, this property does not inherently suggest a need for closer monitoring for drug toxicity.
- High therapeutic index indicates a wide margin of safety for a drug, meaning that the effective dose is significantly lower than the toxic dose. A high therapeutic index implies that the drug has a wide safety margin and is less likely to cause drug toxicity.
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