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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Developing a survey on teen pregnancies is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific topic that may not be relevant or important for the whole population. A survey also requires time and resources to design, distribute, and analyze.

Choice B reason: Holding a focus group to discuss immunizations is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific topic that may not be representative of the community's health needs and concerns. A focus group also requires recruitment, facilitation, and interpretation of the participants' views.

Choice C reason: Interviewing the elderly at the senior center is not a priority intervention for a public health nurse who is assigned to a new community. This is a specific group that may not reflect the diversity and characteristics of the whole population. An interview also requires consent, rapport, and recording of the responses.

Choice D reason: Performing a windshield survey is a priority intervention for a public health nurse who is assigned to a new community. This is a general method that allows the nurse to observe and assess various aspects of the environment that affect the health and well-being of the population. A windshield survey also requires minimal resources and can be done quickly and easily. A windshield survey is a method of assessing the health needs and resources of a community by driving or walking around and observing various aspects of the environment, such as housing, transportation, services, and safety. This is a priority intervention for a public health nurse who wants to get a comprehensive overview of the community and identify its strengths and weaknesses.

A. Black tag B. Red tag C. Green tag D. Yellow tag

Correct Answer is B

Explanation

Choice A reason: A black tag is not the appropriate priority tag for this client, as it indicates that the client is dead or has injuries that are incompatible with life. A black tag is used for clients who have no signs of life, such as pulse, respiration, or pupillary response, or who have severe injuries that cannot be treated with the available resources, such as massive head trauma, decapitation, or incineration. A black tag means that no further care or intervention is provided to the client.

Choice B reason: A red tag is the appropriate priority tag for this client, as it indicates that the client has life-threatening injuries that require immediate attention and treatment. A red tag is used for clients who have compromised airway, breathing, or circulation, such as respiratory distress, shock, severe bleeding, chest pain, or head injury. A red tag means that the client is given the highest priority and is treated as soon as possible.

Choice C reason: A green tag is not the appropriate priority tag for this client, as it indicates that the client has minor injuries that do not require urgent care or intervention. A green tag is used for clients who have stable vital signs and can walk or move without assistance, such as abrasions, sprains, fractures, or minor burns. A green tag means that the client is given the lowest priority and is treated after all other clients.

Choice D reason: A yellow tag is not the appropriate priority tag for this client, as it indicates that the client has serious injuries that require observation and treatment within a short time frame. A yellow tag is used for clients who have potential complications or deterioration of their condition, such as abdominal pain, pelvic injury, open wounds, or spinal injury. A yellow tag means that the client is given the second highest priority and is treated within 30 to 60 minutes.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The public health nurse is assigned to the population of clients in an inner city community. The nurse identifies which of the following as a priority intervention.

Correct Answer is D

Explanation

A client is brought to the Emergency Department as one of the first victims of a train accident. The client reports light-headedness, a weak pulse, and uncontrolled bleeding. Which priority tag should a triage nurse use to categorize this client?

Correct Answer is B

Explanation

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