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 B

Explanation

Choice A rationale

Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.

Choice B rationale

Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.

Choice C rationale

Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.

Choice D rationale

Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.

A. Boggy fundus 1 cm above the umbilicus B. Fundus rotated to the right C. Blood pressure: 90/62 mm Hg D. Voided 200 mL of clear yellow urine E. Heart rate: 96 beats/minute F. IV infusing at 125 mL/hr G. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing H. Episiotomy: Intact with no redness

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

Explanation

Based on the provided information, the following notations require immediate follow-up:

Boggy fundus 1 cm above the umbilicus: A boggy (soft) fundus can indicate uterine atony, a condition in which the uterus fails to contract after delivery. This can lead to postpartum hemorrhage, a serious and potentially life-threatening condition.
Fundus rotated to the right: A displaced fundus can be a sign of a distended bladder, which can interfere with uterine contraction and lead to postpartum hemorrhage.
Blood pressure: 90/62 mm Hg: While this blood pressure isn’t extremely low, it is on the lower end of normal. Given the potential for postpartum hemorrhage indicated by the other findings, this should be monitored closely.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

Correct Answer is B

Explanation

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

Explanation

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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?