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

Answer and Explanation

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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Correct Answer is A,B,C,D

Explanation

This client has the highest priority, as he or she may be experiencing an acute asthma attack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.

B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.

This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.

C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground.

This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inﬂammation.

D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.

A. Increase the warfarin dose. B. Withhold the heparin and continue the same dose of warfarin. C. Decrease the heparin dose. D. D Increase the heparin dose and decrease the warfarin dose.

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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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A,B,C,D

Explanation

Correct Answer is B

Explanation

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