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 A

Explanation

Choice A rationale

The administration of crystalloid fluids in the first 24 hours following a burn incident promotes fluid resuscitation due to capillary leaking. In the aftermath of a burn, there is a disruption of the normal fluid balance in the body, leading to increased capillary permeability and fluid shifts. This can result in a condition known as burn shock, characterized by decreased blood volume and inadequate tissue perfusion. The administration of crystalloid fluids helps to restore intravascular volume, improve tissue perfusion, and prevent burn shock. It also minimizes burn wound conversion and reduces the incidences of post-burn renal failure, life-threatening electrolyte disturbances, and mortality.

Choice B rationale

While restoration of electrolyte balance is an important aspect of burn management, it is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. Electrolyte imbalances in burn patients are usually a result of the systemic inflammatory response, fluid shifts, and renal dysfunction that can occur after a burn. These imbalances are typically managed through careful monitoring and specific electrolyte replacement therapies, rather than through the initial administration of crystalloid fluids.

Choice C rationale

Replacement of insensible water loss is another important aspect of burn management, but it is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. Insensible water loss occurs through evaporation from the burn wound surface and can be significant in burn patients. However, this is typically managed through the maintenance of a humidified environment and specific fluid replacement strategies, rather than through the initial administration of crystalloid fluids.

Choice D rationale

Extension of plasma until blood is available is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. While blood products may be required in the management of severe burns, particularly if there is significant blood loss or hemodynamic instability, the initial focus of fluid resuscitation in burn patients is on the administration of crystalloid solutions to restore intravascular volume and improve tissue perfusion.

A. Administer morphine as prescribed. B. Monitor the patient’s vital signs. C. Apply a cold pack to the affected area. D. Arrange for an X-ray of the left shoulder.

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

Explanation

Choice A rationale

Administering morphine as prescribed would help to manage the patient’s reported pain.

Choice B rationale

Monitoring the patient’s vital signs is crucial in assessing the patient’s physiological response to the fall and ensuring stability.

Choice C rationale

Applying a cold pack to the affected area can help to reduce swelling and alleviate pain.

Choice D rationale

Arranging for an X-ray of the left shoulder would help to identify any potential fractures or other injuries resulting from the fall.

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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

Correct Answer is A

Explanation

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

Explanation

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As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.Which interventions should you perform?

Which client statements require follow-up teaching by the nurse? Select all that apply.

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Which client statement or behavior is most likely associated with their current condition?

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?