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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Verify the prothrombin time (PT).
While it is important to verify coagulation status in patients with atrial fibrillation to ensure they are not at high risk for bleeding, this is not the most critical step immediately prior to
cardioversion. The PT is more relevant if anticoagulation therapy is being managed.
B. Administer prescribed sedative.
Administering a sedative is important for patient comfort during the procedure, but it is not the most critical step that directly affects the success and safety of the cardioversion itself.
C. Select a monitor lead with a tall R wave.
Selecting a monitor lead with a tall R wave helps in accurately synchronizing the cardioversion shock with the R wave, but this is secondary to activating the synchronization mode which is critical to avoid delivering a shock during the vulnerable period of the cardiac cycle.
D. Activate the synchronization mode.
This is the correct answer. The most important action before deploying the current for cardioversion is to ensure the defibrillator is in synchronization mode. Synchronization ensures that the electrical shock is delivered at the correct time during the cardiac cycle, specifically on the R wave of the QRS complex, to avoid inducing ventricular fibrillation. This is crucial for
patient safety.
Correct Answer is D
Explanation
A. Bruising of the skin is not typically associated with acute gastritis caused by contaminated water. While bruising may be a sign of other medical conditions or complications, it is not directly related to gastritis.
B. Low-grade fever can be a symptom of gastritis, especially if it is caused by an infectious agent. However, it is not typically a severe or emergent symptom that requires immediate reporting unless it is accompanied by other concerning symptoms.
C. Abdominal cramping is a common symptom of gastritis and may occur due to inflammation of the stomach lining. While it should be monitored, it is not as concerning as the potential complication indicated by option D.
D. Bloody emesis (vomiting blood) is a serious symptom that can indicate severe gastritis or complications such as gastrointestinal bleeding. It is essential to report this symptom promptly as it may require immediate medical attention and intervention.
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