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","B","D"]

Explanation

The correct answer isa. Place a bedside commode next to bed.,b. Measure neurological vital signs every 4 hours.,d. Encourage family to participate in the client’s care.

Choice A rationale:

Placing a bedside commode next to the bed helps prevent falls and promotes independence in toileting, which is crucial for stroke patients who may have mobility issues.

Choice B rationale:

Measuring neurological vital signs every 4 hours is essential to monitor for any changes in the patient’s condition, which can help in early detection of complications.

Choice C rationale:

Suctioning the oral cavity every 4 hours is not typically necessary unless the patient has specific issues with swallowing or secretion management.Routine suctioning can also cause discomfort and potential injury.

Choice D rationale:

Encouraging family to participate in the client’s care provides emotional support and helps in the rehabilitation process.Family involvement can improve the patient’s motivation and adherence to the rehabilitation plan.

Choice E rationale:

Playing classical music in the room can be soothing and beneficial for some patients, but it is not a standard intervention for stroke rehabilitation.The effectiveness of music therapy can vary based on individual preferences.

A. Her fasting 1-hour glucose screening level, which was done 1 week prior B. Her 3-hour oral glucose tolerance test results C. a two-hour postprandial of 220 mg/dL

Correct Answer is ["A","B","C"]

Explanation

Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).

The client has gestational diabetes mellitus (GDM), which is a condition that affects some pregnant women and causes high blood sugar levels. This is bad during pregnancy because it can increase the risk of complications for both the mother and the baby, such as preeclampsia, macrosomia, birth trauma, neonatal hypoglycemia, and congenital anomalies. The client needs to follow a diet and exercise plan to control her blood sugar levels and prevent further complications. She may also need to take insulin injections or oral medications if diet and exercise are not enough. The client should monitor her blood sugar levels regularly and report any abnormal results to her health care provider. The client should also have regular prenatal visits and ultrasounds to check the growth and development of the baby.

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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

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is ["A","B","C"]

Explanation

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