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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment: Routine irrigation is not typically necessary unless instructed for debris removal. Over-manipulation may increase the risk of infection or injury to the healing eye.
B. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: While sunglasses can protect the eyes from UV light, strict limitation of sunlight is not usually required for 2 weeks. Standard protective measures and avoiding direct glare are sufficient.
C. Avoid straining at stool, bending, or lifting heavy objects: These activities increase intraocular pressure, which can compromise the surgical site and healing process after cataract extraction. Avoiding them is critical to prevent complications such as wound dehiscence or hemorrhage.
D. Do not read without direct lighting for 6 weeks: Reading is generally safe after cataract surgery as long as the client uses appropriate lighting. There is no standard requirement to avoid reading for 6 weeks.
Correct Answer is B
Explanation
A. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet: While verifying a DNR order is important, not all advance directives are represented by a bracelet. This action alone does not clarify the client’s wishes or the specifics of the living will.
B. Seek clarification of the type of advance directive the client has: Living wills and other advance directives vary in scope and specificity. Confirming the type of directive ensures that care aligns with the client’s legally documented wishes and guides future interventions appropriately.
C. Explain that living wills cannot be followed by emergency personnel: Emergency personnel can follow advance directives if they are clearly documented and accessible. Saying they cannot be followed is inaccurate and may create mistrust with the family.
D. Schedule a client and family conference to review the plan of care: A conference may be helpful later for education and care planning, but it does not address the immediate need to clarify the client’s specific directives after an emergency intervention.
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