A nurse is reviewing the results of a functional status assessment for an older adult client using the Katz Index of Independence in Activities of Daily Living (ADLs). The nurse notes that the client scored 4 out of 6 on this tool.

What does this score indicate?

The client is independent in all ADLs.

The client needs assistance with two ADLs.

The client is dependent on others for all ADLs.

The client has difficulty with four ADLs.

Answer and Explanation

The Correct Answer is B

The correct answer is B.

The client needs assistance with two ADLs. This is because the Katz Index of Independence in Activities of Daily Living (ADLs) is a tool that measures the client’s ability to perform six basic ADLs independently: bathing, dressing, toileting, transferring, continence, and feeding. The score ranges from 0 to 6, with 6 indicating complete independence, 4 indicating moderate impairment, and 2 or less indicating severe dependence. The score is based on the number of ADLs that the client can perform without supervision, direction, personal assistance, or total care.

Therefore, a score of 4 out of 6 means that the client needs assistance with two ADLs.

Choice A is wrong because it implies that the client is independent in all ADLs, which would require a score of 6 out of 6.

Choice C is wrong because it implies that the client is dependent on others for all ADLs, which would require a score of 0 out of 6.

Choice D is wrong because it implies that the client has difficulty with four ADLs, which would require a score of 2 out of 6.

The normal range for the Katz Index of Independence in Activities of Daily Living (ADLs) depends on the setting and population of the client. For example, one study found that the average score for residents in skilled nursing facilities was 3.1 out of 6. Another study found that the hierarchy of difficulty of the six ADLs from least to greatest was: eating, maintaining continence, transferring, toileting, dressing, and bathing.

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Correct Answer is D

Explanation

The correct answer is D.

Delirium.

The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.

Delirium can affect the client’s cognition, attention, orientation, memory, and behavior.It can also increase the risk of falls, complications, and mortality.

Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.

Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature.Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.

Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.

Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure.Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.

Choice C is wrong because seizures are not a common complication of fever in older adults.

Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.

Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.

Fever-induced seizures are more likely to occur in young children than in older adults.

A. Follow up with the primary care provider regularly. B. Avoid alcohol and tobacco use C. Take over-the-counter sleeping pills as needed. D. Engage in physical and mental activities daily. E. Wear glasses and hearing aids if prescribed.

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

Explanation

The correct answer isA, B and D.

Here is why:.

• Following up with the primary care provider regularly can help detect and treat any medical conditions that may cause or contribute to delirium, such as infections, electrolyte imbalances, or medication side effects.

• Avoiding alcohol and tobacco use can prevent delirium caused by intoxication or withdrawal, as well as improve overall health and cognitive function.

• Engaging in physical and mental activities daily can help maintain brain health, prevent cognitive decline, and reduce stress and boredom that may trigger delirium.

Choice C is wrong because taking over-the-counter sleeping pills as needed can increase the risk of delirium, especially in older adults.Sleeping pills can cause confusion, drowsiness, memory impairment, and falls that may lead to delirium.Instead of sleeping pills, it is better to have good sleep habits such as uninterrupted sleep, avoiding caffeine and naps, and having a regular bedtime routine.

Choice E is wrong because wearing glasses and hearing aids if prescribed can help prevent delirium, not cause it.Sensory impairment such as poor vision and hearing can make a person more prone to delirium, as they may feel disoriented, isolated, or misunderstood.Wearing glasses and hearing aids can help improve communication, orientation, and awareness of surroundings.

Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of one’s surroundings.It usually comes on fast and can be caused by various factors such as fever, infection, surgery, medication, or emotional distress.

Delirium can often be prevented.

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A nurse is reviewing the results of a functional status assessment for an older adult client using the Katz Index of Independence in Activities of Daily Living (ADLs). The nurse notes that the client scored 4 out of 6 on this tool. What does this score indicate?

Nursing Test Bank

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The nurse is caring for an older adult client who has an infection and a fever of 38°C (100.4°F). The nurse should monitor the client for which of the following complications?

Correct Answer is D

Explanation

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

Explanation

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A nurse is reviewing the results of a functional status assessment for an older adult client using the Katz Index of Independence in Activities of Daily Living (ADLs). The nurse notes that the client scored 4 out of 6 on this tool.

What does this score indicate?