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 D

Explanation

A. Palpating the radial pulses might not detect irregularities in pulse rate or rhythm as effectively as auscultation at the apical site.
B. Listening over the carotid artery may be useful in certain situations but is not the preferred method for assessing overall pulse rate.
C. Feeling the dorsalis pedis and posterior tibialis pulses provides information about peripheral circulation but does not assess the overall heart rate.
D. Auscultating the apical pulse is the most accurate method to assess the pulse rate, especially in clients with cardiovascular disease, as it provides direct measurement of heart activity.

A. Imbalanced nutrition, greater than body requirements. B. Deficient fluid volume. C. Excess fluid volume. D. Imbalanced nutrition, less than body requirements.

Correct Answer is D

Explanation

A. This is not applicable in this case. A BMI of 14 kg/m² indicates severe malnutrition, not excess nutrition. The client is at risk for nutritional deficiencies, not an excess of nutrition.
B. While fluid volume might be a concern in severely malnourished clients, the primary issue in this scenario is related to nutrition rather than fluid imbalance. A low BMI suggests insufficient caloric intake.
C. Excess fluid volume is not typically associated with a low BMI. In fact, clients with a BMI this low may show signs of dehydration or fluid loss due to inadequate nutritional intake.
D. This is the most appropriate nursing diagnosis. A BMI of 14 kg/m² is indicative of severe malnutrition and the client is not meeting their nutritional needs, which could lead to further health complications.

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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

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

Correct Answer is D

Explanation

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]

Correct Answer is D

Explanation

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.

When assessing an older adult client, which finding is most indicative of dehydration?

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

When the nurse is obtaining health history during an annual physical examination, the client reports having difficulty with erections for the past 8 months. Which information in the client's history should the nurse consider as a potential reason for erectile dysfunction?