The client is scheduled for a functional assessment using the Functional Independence Measure (FIM). The client asks the nurse, "What is the
purpose of the FIM?" Which nursing response is appropriate?
"It is a tool that is used to determine your maximum level of self-sufficiency.”
"It is a test that determines which activities you feel most comfortable performinG.”
"It is a tool used by insurance companies to determine qualifications for medical reimbursement."
"It is a tool that is used to assess what services you will need a home health aide to perform for you."
The Correct Answer is A
Choice A reason: "It is a tool that is used to determine your maximum level of self-sufficiency.” This nursing response is appropriate because it accurately describes the purpose of the FIM, which is a standardized instrument that measures the client's level of independence in performing 18 activities of daily living and mobility tasks.
Choice B reason: "It is a test that determines which activities you feel most comfortable performinG.” This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a test that measures the client's comfort level, but rather their functional ability.
Choice C reason: "It is a tool used by insurance companies to determine qualifications for medical reimbursement." This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a tool that determines the client's eligibility for insurance coverage, but rather their functional status and progress.
Choice D reason: "It is a tool that is used to assess what services you will need a home health aide to perform for you." This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a tool that evaluates the client's need for home care services, but rather their functional capacity and improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Plantar flexion is not a test that the nurse uses to gain more information about this client's gait because it is a movement of the foot that points the toes downward, not a measure of balance or coordination.
Choice B reason: Romberg is a test that the nurse uses to gain more information about this client's gait because it is a measure of balance and proprioception, which are often impaired in ataxiA. The test involves asking the client to stand with their feet together and arms at their sides, first with their eyes open and then with their eyes closed, while observing for swaying or fallinG.
Choice C reason: Achilles reflex is not a test that the nurse uses to gain more information about this client's gait because it is a measure of the reflex response of the calf muscle when the Achilles tendon is tapped, not a measure of balance or coordination.
Choice D reason: Patellar reflex is not a test that the nurse uses to gain more information about this client's gait because it is a measure of the reflex response of the quadriceps muscle when the patellar tendon is tapped, not a measure of balance or coordination.
Correct Answer is C
Explanation
c) Bilateral lung sounds.
Explanation:
When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of fluid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and fluid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.
While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and affect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admited with complications of left-sided heart failure.
The other options are considered incorrect because they are not the priority assessments when admitting a client with complications of left-sided heart failure.
Option a) Heart sounds: While assessing heart sounds is important in evaluating cardiac function, the priority in this scenario is to assess for pulmonary congestion and impaired gas exchange. Assessing bilateral lung sounds allows the practical nurse to gather immediate information about the client's respiratory status and the presence of fluid in the lungs.
Option b) Chest pain: Chest pain is a significant symptom that should be assessed promptly, as it could indicate various cardiac or respiratory conditions. However, in this specific scenario, the priority is to assess for signs of pulmonary congestion, which can have a more immediate impact on the client's respiratory function.
Option d) Mood and affect: Assessing the client's mood and affect is important for a comprehensive assessment of their emotional well-being. However, when admitting a client with complications of left- sided heart failure, the priority is to assess their physical condition, particularly the respiratory status, to address any immediate concerns related to pulmonary congestion and impaired gas exchange.
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