A client is scheduled for a functional assessment using the Functional Independence Measure (FIM). The client asks the nurse, "What is the purpose of the FIM?" Which nursing response is appropriate?
It is a tool that is used to determine your maximum level of self-sufficiency.
It is a test that determines which activities you feel most comfortable performing.
It is a tool used by insurance companies to determine qualifications for medical reimbursement.
It is a tool that is used to assess what services you will need a home health aide to perform for you.
The Correct Answer is A
Choice A reason: It is a tool that is used to determine your maximum level of self-sufficiency as the appropriate nursing response, as it accurately describes the purpose and function of the FIM. The FIM measures how much assistance you need to perform 18 activities of daily living, such as eating, dressing, toileting, walking, and communicating. The FIM helps to evaluate your functional status, monitor your progress, and plan your rehabilitation goals and interventions. ¹²³
Choice B reason: It is a test that determines which activities you feel most comfortable performing is not an appropriate nursing response, as it does not reflect the objective and standardized nature of the FIM. The FIM is not a subjective or self-reported measure of your preferences or comfort level, but rather an observational and rating scale that assesses your actual performance and independence in various tasks. The FIM uses a 7-point ordinal scale that ranges from 1 (total assistance) to 7 (complete independence) and requires trained and certified raters to administer and score it. ¹²³
Choice C reason: It is a tool used by insurance companies to determine qualifications for medical reimbursement is not an appropriate nursing response, as it does not capture the primary purpose and benefit of the FIM. The FIM is not a financial or administrative tool that determines your eligibility or coverage for medical services, but rather a clinical and research tool that measures your functional outcomes and quality of care. The FIM provides a uniform system of measurement for disability based on the International Classification of Impairment, Disabilities, and Handicaps and allows for comparison and evaluation of different rehabilitation programs and settings. ¹²³
Choice D reason: It is a tool that is used to assess what services you will need a home health aide to perform for you is not an appropriate nursing response, as it does not reflect the comprehensive and multidimensional scope of the FIM. The FIM is not a specific or limited tool that assesses only your home care needs or dependence on others, but rather a general and broad tool that assesses your functional abilities and disabilities in various domains and environments. The FIM covers both motor and cognitive aspects of functioning, such as comprehension, expression, social interaction, problem-solving, and memory. The FIM can be used with all diagnoses within rehabilitation and can be applied across different levels and settings of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Performing carotid massage is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may worsen the condition or cause complications. Carotid massage is a technique that involves applying pressure to the carotid artery in the neck to stimulate the vagus nerve and slow down the heart rate. It is used to treat some types of arrhythmias, such as supraventricular tachycardia. However, carotid massage may dislodge a blood clot or plaque from the carotid artery and cause an embolic stroke, which is a type of ischemic stroke that occurs when a blood clot travels to the brain and blocks a blood vessel. Carotid massage may also cause bradycardia, hypotension, or syncope, which can reduce the blood flow to the brain and worsen the ischemic damage.
Choice B reason: Calling for help is an appropriate action for a nurse to take when a client has signs of a stroke, as it initiates the emergency response and allows for prompt evaluation and treatment. Stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. The sooner the stroke is recognized and treated, the better the chances of survival and recovery. Therefore, the nurse should call for help as soon as possible and activate the stroke protocol in the facility.
Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may cause aspiration or choking. A gag reflex is an involuntary contraction of the throat muscles that prevents foreign objects from entering the airway. It is tested by touching the back of the throat with a tongue depressor or a cotton swab. However, this test is not indicated in a client who has signs of a stroke, as it may trigger vomiting or coughing, which can increase intracranial pressure or cause bleeding. Moreover, giving water to a client who has signs of a stroke may be dangerous, as they may have dysphagia (difficulty swallowing) or facial weakness, which can impair their ability to swallow safely and increase the risk of aspiration pneumonia.
Choice D reason: Administering thrombolytics is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may be contraindicated or harmful depending on the type and timing of the stroke. Thrombolytics are medications that dissolve blood clots and restore blood flow. They are used to treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, thrombolytics are not effective for hemorrhagic stroke, which is caused by bleeding into or around the brain. In fact, thrombolytics may worsen hemorrhagic stroke by increasing bleeding and intracranial pressure. Therefore, thrombolytics should only be given after confirming the type of stroke by imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Thrombolytics should also be given within a specific time window after the onset of symptoms, usually within 3 to 4.5 hours, as they may lose their effectiveness or cause complications if given too late. Therefore, administering thrombolytics is not an action that a nurse can take without proper assessment and orders from the health care provider.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Epidemiology interprets legislation in the community is not a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology is not directly involved in interpreting legislation, but rather in providing evidence and recommendations that can inform policy-making and law-making.
Choice B reason: Epidemiology relates to the health status of a population is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology is the study of how diseases and other health-related factors are distributed and determined in populations. It helps the community health nurse to identify and monitor health problems, trends, and disparities in different groups and areas.
Choice C reason: Epidemiology analyzes and examines the root causes of health outcomes is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology uses various methods and tools to investigate and explain the causes and consequences of diseases and other health-related events. It helps the community health nurse to understand and address the complex and multifactorial factors that influence health, such as biological, environmental, social, behavioral, and economic factors.
Choice D reason: Epidemiology evaluates the effectiveness of nursing interventions is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology applies scientific principles and rigorous designs to assess and compare the outcomes and impacts of different interventions and programs on health. It helps the community health nurse to plan, implement, and evaluate evidence-based practices and policies that can improve health and quality of life.
Choice E reason: Epidemiology defines the burden of disease and determinants of health is a statement that indicates the importance of epidemiology to the community health nurse. Epidemiology measures and compares the frequency, severity, and impact of diseases and other health-related conditions on populations. It helps the community health nurse to prioritize and allocate resources, as well as to advocate for health equity and social justice.
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