An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?

Assist the client with clarifying values about end-of-life care options.

Ask the client how often episodes of sundowning are experienced.

Request to have the client lie as still as possible for the assessment.

Question the client about the frequency of falls in recent months.

Answer and Explanation

The Correct Answer is D

A. This action pertains more to discussions about advance care planning and end-of-life preferences, which may be important but are not directly related to assessing the client's functional status.

B. Episodes of sundowning are associated with changes in behavior, confusion, and agitation in some individuals with dementia, particularly in the late afternoon or evening. While important to assess in certain contexts, it is not directly related to evaluating the client's physical strength and mobility.

C. Asking the client to lie still does not provide information about their functional status or ability to perform activities of daily living.

D. This is the most appropriate action because it directly addresses the client's reported decreased strength and assesses the impact on their functional ability. Falls are a common consequence of reduced strength and mobility in older adults and can provide valuable information about the client's current physical function and safety.

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Correct Answer is B

Explanation

A. While scheduling a client and family conference may be necessary to discuss the plan of care, the immediate concern is to determine the type of advance directive the client has and whether it includes preferences regarding resuscitation.
B. This is the most appropriate action because it addresses the family member's concern and ensures that the client's wishes regarding resuscitation are understood and followed.
C. While checking for a DNR bracelet is important, it does not address the family member's question about why the code was called despite the client having a living will.
D. This statement is incorrect. Living wills can guide decision-making regarding end-of-life care, including resuscitation, depending on the legal requirements and documentation in place.

A. Self-care deficit relative to motor disturbance. B. Risk for aspiration relative to muscle weakness. C. Risk for constipation relative to immobility. D. Impaired physical mobility relative to muscle rigidity.

Correct Answer is B

Explanation

A. Self-care deficit relative to motor disturbance. While self-care deficit is a concern for clients with Parkinson's disease due to motor disturbances, the highest priority is addressing the risk for aspiration to prevent potential life-threatening complications such as aspiration pneumonia.
B. Risk for aspiration relative to muscle weakness. Parkinson's disease can cause muscle weakness and impaired swallowing function, leading to an increased risk of aspiration.
Aspiration pneumonia is a severe complication that requires immediate attention, making this the highest priority nursing problem.
C. Risk for constipation relative to immobility. Constipation is a common problem in Parkinson's disease due to immobility and medication side effects. While constipation should be addressed, it is not as immediately life-threatening as the risk for aspiration.
D. Impaired physical mobility relative to muscle rigidity. Impaired physical mobility is a significant concern in Parkinson's disease, but muscle rigidity does not necessarily pose an
immediate risk of aspiration. Addressing impaired mobility is important for maintaining overall function and quality of life but may not be the highest priority in this scenario.

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An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Correct Answer is B

Explanation

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