The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?

Assess for spinal scoliosis.

Compare shoulder symmetry.

Observe gait while walking.

Palpate for joint nodules.

Answer and Explanation

The Correct Answer is C

A. Assess for spinal scoliosis: While scoliosis can affect posture and mobility, it is less likely to immediately impact the client’s safety in performing daily activities at home.

B. Compare shoulder symmetry: Shoulder asymmetry may indicate musculoskeletal issues but is not the most critical factor in evaluating fall risk or functional independence.

C. Observe gait while walking: Gait assessment provides direct information about balance, coordination, and mobility, which are key indicators of fall risk and home safety. Observing how the client walks helps the nurse plan interventions to prevent injury.

D. Palpate for joint nodules: Detecting nodules can identify conditions such as osteoarthritis, but the presence of nodules alone does not provide immediate insight into functional mobility or home safety.

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Correct Answer is ["B","D","E"]

Explanation

A. Heart sounds: Assessing heart sounds is important for general health monitoring, but it is not directly related to the effectiveness of herpes zoster treatment. Shingles primarily affects the skin and nerves, not cardiac function.

B. Pain scale: Shingles often causes severe neuropathic pain, so monitoring pain levels helps determine if antiviral therapy and analgesics are effective. Pain reduction is a key marker of successful treatment.

C. Bowel sounds: Bowel function is not typically affected by herpes zoster, unless complications from medications occur. It is not a standard measure of treatment effectiveness for shingles.

D. Functional ability: Severe shingles pain can limit mobility and self-care activities. Assessing functional ability helps evaluate whether symptom management is improving quality of life and daily functioning.

E. Skin integrity: Shingles causes a painful vesicular rash that can progress to ulceration or secondary infection. Monitoring healing of skin lesions and prevention of complications directly reflects treatment effectiveness.

A. Reapply a sterile non-adhesive dressing. B. Administer prescribed antibiotics. C. Request a nutrition consult. D. Limit visitors to immediate family only.

Correct Answer is B

Explanation

A. Reapply a sterile non-adhesive dressing: While maintaining a clean dressing is important to prevent further contamination, it does not address the underlying MRSA infection causing the wound to worsen.

B. Administer prescribed antibiotics: Prompt administration of antibiotics is the priority because the wound is infected with MRSA and is enlarging, indicating active infection that requires systemic treatment to prevent sepsis and promote healing.

C. Request a nutrition consult: Adequate nutrition supports wound healing, but it is a secondary intervention and does not immediately treat the infection or stop its progression.

D. Limit visitors to immediate family only: Limiting visitors may reduce infection risk to others, but it does not directly treat the MRSA infection or address the acute worsening of the wound.

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The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

Correct Answer is B

Explanation

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