An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Screen client for alcohol or controlled drug abuse.

Evaluate client for side effects of routine medications.

Instruct client to demonstrate activities of daily living.

Focus questions to evaluate long term memory.

Answer and Explanation

The Correct Answer is C

A.   Alcohol or drug abuse screening may be important but does not directly assess functional ability.
B.   Medication side effects can impact functionality, but ADLs are a direct measure of independence.
C.   Assessing a client's ability to perform activities of daily living (ADLs) is crucial for determining their functional status and whether they can live independently or need assistance.
D.   Long-term memory evaluation is less important than assessing the client's ability to perform daily tasks.

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Correct Answer is B

Explanation

A. While subjective data is important, it should be categorized appropriately based on relevance to the diagnosis, not just placed in the notes section without context.
B. Documenting the client’s history directly related to the current admission diagnoses ensures the information is relevant and addresses the issue at hand. It helps prioritize concerns specific to the new onset seizures.
C. Recording at the bedside can be useful for accuracy but is not as effective for thoroughness as
entering information directly in the client’s electronic medical record with appropriate organization.
D. Documenting assessment findings at the nursing station might delay real-time recording and cause the information to be less accurate, especially if not recorded immediately after assessment.

A. Anal mucosa prolapse and loose sphincter tone. B. Dried dark red blood on swollen external hemorrhoids. C. Serosanguineous and purulent exudate from anus. D. Tears of the anal mucosa with old blood around anus.

Correct Answer is B

Explanation

A. Anal mucosa prolapse may be a concern but would not explain the appearance of the dark red blood and external hemorrhoidal mass.
B. Dried, dark red blood on swollen external hemorrhoids suggests hemorrhoidal bleeding, which is common and associated with the appearance of a purple, shiny tissue mass.
C. Serosanguineous or purulent exudate suggests infection or other concerns but does not fit the description of the observed finding in this case.
D. Tears in the anal mucosa with old blood may occur, but they are not as likely to present as a shiny, purple mass with dark red blood on the surface.

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An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Which assessment finding, obtained during chest auscultation, should the nurse consider a normal finding?

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal?

The nurse is doing a health assessment of a client who smoked three packs of cigarettes every day for the last twenty years before quitting two years ago. How should the nurse document the client's pack-years? (Enter the numerical value only.)

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

In assessing an adult client, the nurse calculates the body mass index (BMI) as 14 kg/m2. Which nursing problem should be included in this client's plan of care? Reference Range: Body mass index (BMI) [normal 18.0 to 24.9 kg/m2]