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 A
Explanation
This statement indicates that the client has reached a level of acceptance of his prognosis, as he expresses a sense of peace, gratitude, and hope. He has found sources of strength and comfort from his faith and family, and he does not show signs of denial, anger, bargaining, or depression.
The other options are not correct because:
B . This statement indicates that the client is in the stage of rationalization, as he tries to justify or minimize his condition by stating a fact that does not address his feelings or needs.
C. This statement indicates that the client is in the stage of anger, as he shows resentment and hostility towards those who challenge his optimism or reality.
D. This statement indicates that the client is in the stage of blame, as he implies that his condition could have been prevented or treated if the doctor had diagnosed it earlier.
Correct Answer is ["2"]
Explanation
Rationale: The nurse should calculate the dose based on the concentration of the medication. Since the suspension contains 500 mg of acetaminophen per 15 mL, a 1,000 mg dose requires 30 mL (2 tablespoons) of the suspension.
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