An older adult client arrives to the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?
Request to have the client lie as still as possible for the assessment.
Question the client about the frequency of falls in recent months.
Ask the client how often episodes of sundowning are experienced.
Assist the client with clarifying values about end-of-life care options.
The Correct Answer is B
A. Request to have the client lie as still as possible for the assessment: This action is not relevant to a functional assessment related to decreased strength. Functional assessments typically involve active movements and observations.
B. Question the client about the frequency of falls in recent months: Asking about falls helps assess the impact of decreased strength on the client's functional abilities and safety. Frequent falls can indicate impaired mobility or balance, which is important for understanding the client’s functional status.
C. Ask the client how often episodes of sundowning are experienced: Sundowning is related to cognitive and behavioral changes typically seen in dementia, not directly related to the physical strength issues being assessed.
D. Assist the client with clarifying values about end-of-life care options: While important, this action is not related to a functional assessment of physical strength and ability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Documenting the findings is important for record-keeping but is not the immediate priority. The presence of clear fluid could indicate cerebrospinal fluid (CSF) leakage, which requires immediate assessment.
B. Testing the fluid on the dressing for glucose is the most critical action. CSF is high in glucose, so this test helps determine if the clear fluid is indeed CSF, which is a significant postoperative complication requiring immediate intervention.
C. Marking the drainage area and continuing to monitor is not sufficient in the face of potential CSF leakage. Immediate action is needed to confirm the nature of the fluid.
D. Changing the dressing with a compression bandage may be necessary, but the immediate priority is to confirm whether the fluid is CSF before taking further steps.
Correct Answer is B
Explanation
A. Initiate seizure precautions: Seizure precautions are not directly related to the administration of dopamine for hypotension. Dopamine primarily affects cardiovascular function.
B. Measure urinary output every hour: Monitoring urinary output is essential because dopamine can increase renal perfusion, and adequate urine output indicates effective renal function and response to treatment.
C. Monitor serum potassium frequently: While monitoring potassium levels might be necessary in some situations, it is not a primary focus of dopamine therapy unless there are specific concerns about electrolyte imbalances.
D. Assess pupillary response to light hourly: Pupillary response is not a primary concern when administering dopamine unless there are symptoms of neurological compromise, which is not indicated in this scenario.
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