A nurse is collecting data from a client who has depression to identify his ability to perform activities of daily living (ADLs) prior to discharge. Which of the following data should the nurse collect? (Select all that apply.)
Ability to dress himself
Ability to identify how often he should schedule his car for an oil change
Ability to bathe himself
Ability to perform oral hygiene
Ability to balance his bank account
Correct Answer : A,C,D
Choice A reason: The ability to dress oneself is a basic ADL and is important for independence after discharge.
Choice B reason: Scheduling car maintenance is not considered a basic ADL; it is an instrumental activity of daily living (IADL), which is not typically assessed for depression-related ADLs.
Choice C reason: The ability to bathe oneself is another basic ADL that is crucial for self-care and should be assessed before discharge.
Choice D reason: Performing oral hygiene is a fundamental ADL and should be included in the assessment.
Choice E reason: Balancing a bank account is an IADL and, similar to choice B, is not typically part of the basic ADL assessment for a client with depression.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: While aspirin does have anti-inflammatory properties, the primary reason for prescribing it post-myocardial infarction is not to reduce inflammation.
Choice B reason: Aspirin can provide pain relief, but this is not the main purpose of its prescription following a myocardial infarction.
Choice C reason: Fever prevention is not a relevant effect in the context of aspirin use for coronary artery disease.
Choice D reason: Aspirin is prescribed to prevent blood clotting. It inhibits platelet aggregation, which is crucial in reducing the risk of further heart attacks by preventing clots that can occlude coronary arteries.
Correct Answer is A
Explanation
Choice A Reason:Grandiosity refers to an exaggerated sense of one's importance, power, knowledge, or identity—even with little evidence to support this. In bipolar disorder, grandiosity can occur during both manic and hypomanic episodes. Individuals experiencing grandiosity may believe they have special powers, abilities, or are destined for greatness. This behavior aligns with the client's statement about revolutionizing the industry, which reflects an inflated sense of self-importance.
Choice B Reason:Flight of ideas is characterized by rapid, continuous, and often disjointed thoughts. It is a symptom commonly seen in manic episodes of bipolar disorder. However, the client's statement does not specifically indicate flight of ideas.
Choice C Reason:Confabulation refers to the production of fabricated or distorted memories or information. It is not directly related to the client's statement about revolutionizing the industry
Choice D Reason:Clang associations involve the use of rhyming or similar-sounding words without logical connections. While it is a symptom seen in some mental health conditions, it is not directly applicable to the client's behavior described in the question.
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