The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?
Request to have the client lie as still as possible for the assessment.
Ask the client how often episodes of sundowning are experienced.
Question the client about the frequency of falls in recent months.
Assist the client with clarifying values about end-of-life care
The Correct Answer is C
A) Incorrect - Requesting the client to lie still may be relevant for certain assessments, but it is not specific to the situation described in the question.
B) Incorrect - Inquiring about episodes of sundowning is more relevant for clients with cognitive impairment and is not directly related to the client's weight loss and decreased energy and appetite.
C) Correct - Questioning the client about the frequency of falls is important, as falls can contribute to weight loss, decreased energy, and appetite changes in older adults.
D) Incorrect - Assisting the client with clarifying values about end-of-life care is a valuable nursing intervention but is not the priority in this assessment scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is the first action that the PN should take because the catheter size and balloon volume are inappropriate for the client. A #18 urinary catheter is too large for a female client who weighs 50 kg, and a 30 mL balloon may cause bladder trauma or discomfort. The PN should consult with the charge nurse and obtain a smaller catheter (such as #14 or #16) with a 10 mL balloon.

Correct Answer is ["0.75"]
Explanation
To calculate the amount of mL to administer, the PN should use the following formula:
mL = (mcg x 1 mg/1000 mcg) / (mg/mL)
Plugging in the given values, we get:
mL = (150 x 1/1000) / (0.2)
mL = 0.15 / 0.2
mL = 0.75
Therefore, the PN should administer 0.75 mL of octreotide subcutaneously.

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