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 D

Explanation

The presence of purulent drainage at the wound indicates a potential infection, and monitoring the client's WBC count is an important laboratory value to assess for signs of infection. An elevated WBC count, specifically an increase in the neutrophil count (neutrophilia), can indicate an active infection and provide important information for the healthcare provider when evaluating the wound.

While hematocrit, platelet count, and creatinine level are essential laboratory values to assess the client's overall condition, they may not provide specific information regarding the presence of infection or purulent drainage at the wound site.

A. Disturbed Body Image. B. Interrupted Family Processes. C. Imbalanced Nutrition: less than body requirements. D. Noncompliance with treatment regimen.

Correct Answer is C

Explanation

Imbalanced Nutrition: less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications. Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

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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

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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