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."

Answer and Explanation

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.

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

Explanation

Choice A reason: "I may experience urinary incontinencE." This statement does not indicate the need for additional teaching because it is truE. Urinary incontinence is a common symptom of MS due to nerve damage affecting the bladder control.

Choice B reason: "I should not exercise because this may trigger an exacerbation." This statement indicates the need for additional teaching because it is falsE. Exercise is beneficial for people with MS as it can improve strength, balance, mobility, fatigue, mood, and quality of lifE. Exercise does not cause or worsen MS relapses.

Choice C reason: "I should alternate the eye patch every other day to help with the double vision." This statement indicates the need for additional teaching because it is not recommendeD. Eye patching is not an effective treatment for double vision caused by MS, as it can impair depth perception, increase eye fatigue, and delay recovery. Eye patching should only be used temporarily and under medical supervision.

Choice D reason: "I may experience visual disturbances." This statement does not indicate the need for additional teaching because it is truE. Visual disturbances are common in MS due to inflammation or damage of the optic nerve or other parts of the visual pathway. Visual disturbances can include blurred vision, reduced color vision, pain in the eye, and loss of vision.

Choice E reason: "I need to check the water temperature before I take a batH." This statement does not indicate the need for additional teaching because it is truE. People with MS may have impaired sensation and temperature regulation, which can increase the risk of burns or hypothermia when exposed to hot or cold water. Checking the water temperature before bathing can prevent injury and discomfort.

A. The child looks at the floor when answering the nurse's quesons. B. The mother describes in detail what she did for her injured child. C. The abrasions on the child's arms, legs, and chest have healed. D. The injury descripon by the mother varies from the child's version.

Correct Answer is D

Explanation

- Child abuse is the intentional or neglectful physical, emotional, or sexual harm or injury of a child by a parent, caregiver, or another person who has a relationship of trust or responsibility with the child. Child abuse can have serious and long-lasting consequences for the child's health, development, and well-being.

- The practical nurse (PN) has a legal and ethical duty to identify, report, and prevent child abuse. The PN should be alert for any signs and symptoms of child abuse, such as unexplained or inconsistent injuries, bruises, burns, fractures, or scars; behavioural changes, such as fear, anxiety, aggression, withdrawal, or depression; poor hygiene, nutrition, or growth; lack of supervision, medical care, or education; or sexualized behaviours or knowledge.

- The PN should also conduct a thorough and sensitive assessment of the child and the family situation, using open-ended questions, active listening, and a non-judgmental attitude. The PN should compare the history and physical findings of the child with the expected developmental milestones and normal variations for the child's age and stage. The PN should also document any relevant information in an objective and factual manner.

- When the mother of a school-aged boy tells the PN that he fell out of a tree and hurt his arm and shoulder, the PN should assess the child's injury and compare it with the mother's explanation. The most significant indicator of possible child abuse in this scenario is if the injury description by the mother varies from the child's version. This may suggest that the mother is lying or covering up the true cause of the injury, which may be intentional or accidental harm by herself or someone else. A discrepancy between the mother's and the child's stories may also indicate that the child is afraid or coerced to hide the truth about the abuse.

- Therefore, option D is the correct answer, while options A, B, and C are incorrect.

- Option A is incorrect because the child looking at the floor when answering the nurse's questions may not be a sign of abuse, but rather a sign of shyness, embarrassment, pain, or discomfort.

Option B is incorrect because the mother describing in detail what she did for her injured child may not be a sign of abuse, but rather a sign of concern, care, or guilt.

Option C is incorrect because the abrasions on the child's arms, legs, and chest having healed may not be a sign of abuse, but rather a sign of normal wound healing or previous accidents.

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The client is scheduled for a functional assessment using the Functional Independence Measure (FIM). The client asks the nurse, "What is thepurpose of the FIM?" Which nursing response is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse provides education to a client who is newly diagnosed with multiple sclerosis (MS). Which client statements indicate the need for additional teaching? SELECT ALL THAT APPLY

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

Explanation

The mother of a school-aged boy tells the praccal nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the praccal nurse (PN) note as the most significant indicator of possible child abuse?

Correct Answer is D

Explanation

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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?