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","B","F"]

Explanation

A. Skin turgor refers to the elasticity of the skin, which can be affected by various conditions, including malignancy. The nurse should assess for any skin changes near the lump to identify any unusual signs.
B. The nurse should document the precise location of the mass, noting whether it is near the nipple or in another quadrant of the breast. This will help with future imaging and assessment.
C. While the history is important, it does not fall under objective findings that the nurse would document during the physical exam.
D. This is part of the patient’s history, not a direct observation during the physical exam, so it is not included in the documentation of objective findings of the breast mass.
E. Orientation refers to the patient’s mental status and does not relate to the characteristics of the breast mass.
F. The nurse should note the consistency of the mass (e.g., hard, firm, or soft). A firm, non-tender mass is often concerning for malignancy and should be documented.

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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","F"]

Explanation

Correct Answer is D

Explanation

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