The nurse is preparing to perform a functional assessment of an older patient. What is an appropriate approach for the nurse to take?

Review the medical record for information on the patient's abilities.

Ask the patient's wife how he does when performing tasks.

Ask the patient's physician for information on the patient's abilities.

Observe the patient's ability to perform the tasks.

Answer and Explanation

The Correct Answer is D

A.   Although the medical record can provide background information, it does not give the real-time assessment of the patient's current functional abilities.
B.   While this information can be valuable, observing the patient directly provides the most accurate assessment of his abilities.
C.   The physician’s perspective is important but may not fully capture the patient's day-to-day functional capacity.
D.   Direct observation allows the nurse to assess the patient’s current functional status and make necessary adjustments to the care plan.

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Correct Answer is A

Explanation

A. Palpation should be done after auscultation to avoid altering the bowel sounds. Palpation can cause changes in the sounds, making it difficult to assess accurately.
B. It is advisable to auscultate bowel sounds when the patient is not actively eating, so this action is appropriate.
C. This is the correct duration for assessing bowel sounds. Auscultating for 3-5 minutes is within the standard practice.
D. If the client has an NG tube, clamping it before auscultation is appropriate as it prevents additional noises or interference from the tube.

A. Tear of rotator cuff. B. Adhesive capsulitis. C. Joint effusion. D. Dislocated shoulder

Correct Answer is D

Explanation

A. A tear in the rotator cuff usually results in pain and limited range of motion, but it doesn't typically cause a length discrepancy in the arms.
B. Also known as frozen shoulder, this condition is characterized by limited range of motion but would not cause a discrepancy in arm length.
C. While joint effusion involves fluid accumulation and can cause pain and swelling, it doesn't cause arm length discrepancy or the sudden inability to move the shoulder.
D. A dislocated shoulder often results in an obvious deformity, such as a length discrepancy between the arms, and could prevent movement due to pain.

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The nurse is preparing to perform a functional assessment of an older patient. What is an appropriate approach for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing a nurse auscultating a client's bowel sounds. Which of the following actions requires intervention by the charge nurse?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

Which of the following would be considered an expected finding when assessing accommodation in an adult client?

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient.

The movement of the leg laterally then medially, with knee straight is referred to as:

A nurse assesses four clients. Which client assessment will require the nurse to perform an immediate focused assessment?

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?

Which assessment finding(s) for a client with hypothyroidism should the nurse document as abnormal? Select all that apply.