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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect- While missed meals can contribute to glucose fluctuations, the abrupt onset of diabetic ketoacidosis (DKA) suggests a more immediate cause, such as insulin-related factors.
B) Correct- Diabetic ketoacidosis (DKA) occurs due to a lack of sufficient insulin, resulting in the body breaking down fat for energy and producing ketones. While all the options can contribute to DKA, the most likely cause in this scenario is administering too much insulin. This can lead to a rapid drop in blood glucose levels, causing the body to initiate ketone production for energy.
C) Incorrect- While infections can contribute to insulin resistance, they are not the most common cause of the rapid development of diabetic ketoacidosis (DKA) seen in this scenario.
D) Incorrect- Eating extra food would likely lead to higher glucose levels but wouldn't cause the rapid and severe ketone production characteristic of diabetic ketoacidosis (DKA).
Correct Answer is B
Explanation
A) Incorrect - The APTT value being two times the control value indicates that the client's anticoagulation is within the therapeutic range. There is no need to increase the warfarin dose.
B) Correct - With the APTT value within the target range and the PT and INR values also normal, the nurse should continue the same dose of warfarin and withhold the heparin.
C) Incorrect - Decreasing the heparin dose is not indicated, as the client's APTT is already within the therapeutic range.
D) Incorrect - Increasing the heparin dose and decreasing the warfarin dose is not necessary, as the client's anticoagulation levels are appropriate.
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