The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.
Which action should the nurse include during the assessment?

Ask the patient how often episodes of sundowning are experienced.

Inquire about the frequency of falls in recent months.

Request the patient to lie as still as possible for the assessment.

Assist the patient with clarifying values about end-of-life care options.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Asking the patient how often episodes of sundowning are experienced is more relevant in assessing cognitive function, particularly in patients with dementia. It is not directly related to the patient’s weight loss or decreased energy and appetite.

Choice B rationale

Inquiring about the frequency of falls in recent months is crucial in a functional assessment of an older patient who has lost weight and reports a decrease in energy and appetite. Weight loss and decreased energy can increase the risk of falls, which can lead to serious injuries and further functional decline.

Choice C rationale

Requesting the patient to lie as still as possible for the assessment is not directly related to the patient’s weight loss or decreased energy and appetite. It might be necessary for certain physical examinations or procedures, but it is not the most relevant action in this context.

Choice D rationale

Assisting the patient with clarifying values about end-of-life care options is an important aspect of geriatric care, especially in patients with serious illnesses. However, it is not directly related to the patient’s weight loss or decreased energy and appetite.

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Correct Answer is D

Explanation

Choice A rationale

While securing the room with padded walls and minimal furnishings is an important aspect of seclusion, it is not the most important intervention immediately after seclusion. The safety of the client is paramount, and observing for extrapyramidal symptoms, such as dystonia, is crucial as haloperidol, an antipsychotic medication known to have the potential for causing extrapyramidal side effects, was administered.

Choice B rationale

Releasing the client as soon as composure is regained is not the most important intervention. The client’s mental and physical health needs to be continuously monitored, especially for side effects of the medication administered.

Choice C rationale

Providing one-on-one observation at all times is important, but it is not the most important intervention immediately after seclusion. The priority is to monitor for any adverse effects of the medication administered.

Choice D rationale

Observing for extrapyramidal symptoms, such as dystonia, is the most important intervention immediately after seclusion because haloperidol is an antipsychotic medication known to have the potential for causing extrapyramidal side effects.

A. Uterine atony B. Wound dehiscence C. Infection D. Hemorrhage

Correct Answer is A

Explanation

Choice A rationale

Uterine atony refers to a condition where the uterus fails to contract sufficiently during and after childbirth. This lack of contraction can lead to excessive bleeding, also known as postpartum hemorrhage. This is because the contractions of the uterus after delivery help to compress the blood vessels and prevent bleeding. Therefore, uterine atony can cause a patient to hemorrhage.

Choice B rationale

Wound dehiscence refers to a surgical complication where an incision reopens either internally or externally. It can cause pain, infection, and organ protrusion. However, it is not directly associated with hemorrhaging.

Choice C rationale

Infection refers to the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. While severe infections can lead to sepsis and disseminated intravascular coagulation, which can cause bleeding, they do not directly cause hemorrhaging.

Choice D rationale

Hemorrhage is a symptom, not a condition. It refers to excessive bleeding which can occur due to various conditions, including uterine atony.

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The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.Which action should the nurse include during the assessment?

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Correct Answer is D

Explanation

The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

Correct Answer is A

Explanation

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

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The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.
Which action should the nurse include during the assessment?