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 C

Explanation

A. Glucose and calcium levels: While hyperglycemia can occur secondary to stress, glucose and calcium are not the primary indicators of severity in a thyrotoxic crisis.

B. Blood and urine cultures: Cultures are important if infection is suspected as a trigger, but they do not reflect the systemic impact of a thyrotoxic crisis itself.

C. Renal and liver function tests: Thyrotoxic crisis can lead to multi-organ stress, including hepatic dysfunction and impaired renal perfusion. Monitoring liver enzymes and renal function helps detect complications early and guide interventions.

D. Electrolytes and hemoglobin: Electrolytes may fluctuate and anemia may exist, but they are not the most critical values to monitor during the acute phase of a thyrotoxic crisis compared with organ function indicators.

A. Demonstrate to the PN how to position the client more effectively for the procedure. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Assume care of the client and assign the PN to the care of a different client. D. Acknowledge that the PN has positioned the client safely and correctly.

Correct Answer is A

Explanation

A. Demonstrate to the PN how to position the client more effectively for the procedure: The nurse is responsible for ensuring correct positioning to optimize visualization and safety during a sigmoidoscopy. Providing guidance or demonstration supports safe practice and enhances the PN’s competence.

B. Arrange for unlicensed assistive personnel to assist the PN during the procedure: While additional assistance may be helpful, it does not address whether the client is positioned correctly, which is the immediate priority for procedural safety and effectiveness.

C. Assume care of the client and assign the PN to the care of a different client: Reassigning responsibilities may delay the procedure and does not utilize the opportunity for the PN to learn proper technique. Collaboration and teaching are preferred.

D. Acknowledge that the PN has positioned the client safely and correctly: Simply acknowledging the position without verifying or guiding may result in suboptimal visualization or risk to the client. The nurse must ensure accuracy rather than assume correctness.

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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

Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis?

Correct Answer is C

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is A

Explanation

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply.

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?

A young adult is brought to the emergency department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? Select all that apply.

The nurse is caring for a client who tests positive for gonorrhea. The client reports having had prior sexually transmitted infections (STIs). Which response should the nurse provide?

The caregiver of a toddler is concerned about the frequency of ear infections and states, "The pediatrician said my child's ear tubes are small and short. What can I do about this?" Which action should the nurse take?

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.