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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While social workers can provide support therapy, they are not typically involved in teaching medical procedures like insulin injection15.
Choice B rationale
Leaving the room and returning later can give the client time to process the information and prepare for learning. It’s important to respect the client’s feelings and readiness to learn15.
Choice C rationale
While it’s true that insulin is a life-saving drug for people with type 1 diabetes, simply explaining this may not address the client’s fears or concerns about self-injection15.
Choice D rationale
Encouraging relaxation techniques can be helpful, but it doesn’t directly address the issue of teaching insulin injection15.
Correct Answer is D
Explanation
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
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