An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?
Encourage the client to lie as still as possible during the assessment.
Question the client about the frequency of falls in recent months.
Assist the client with values clarification about end-of-life care options.
Ask the client how often episodes of sundowning are experienced.
The Correct Answer is B
A functional assessment is an evaluation of an individual's ability to perform activities of daily living (ADLs), which includes tasks such as bathing, dressing, toileting, eating, and mobility. Falls are a common and significant issue among older adults and are a leading cause of injury and hospitalization. Therefore, it is important to assess the client's risk of falling and inquire about any recent falls to develop an appropriate plan of care to prevent falls.
Encouraging the client to lie as still as possible during the assessment is not appropriate as it may not provide an accurate evaluation of the client's ability to perform ADLs.
Additionally, it is important to assess the client's functional status in a way that is safe and comfortable for them.
Assisting the client with values clarification about end-of-life care options is not appropriate during a functional assessment as it is not directly related to the client's ability to perform ADLs.
Asking the client how often episodes of sundowning are experienced is not appropriate during a functional assessment as sundowning is a symptom of dementia and is not directly related to the client's ability to perform ADLs.
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Related Questions
Correct Answer is D
Explanation
A) Incorrect- This is true; the diaphragm should be inserted before sexual activity. However, the main concern in this scenario is the need for refitting after childbirth.
B) Incorrect- This statement is not accurate. While the diaphragm is a form of contraception, it is not considered one of the most effective methods. Long-acting reversible contraceptives
(LARCs) like intrauterine devices (IUDs) and hormonal implants are among the most effective methods.
C) Incorrect- Vaseline lubricant can be used when inserting the diaphragm: Vaseline and other oil-based lubricants can weaken the latex or cause damage to the diaphragm. Water-based lubricants are recommended for use with diaphragms.
D) Correct- The diaphragm is a barrier contraceptive device that is inserted into the vagina before sexual intercourse to prevent pregnancy. However, its effectiveness can be compromised by changes in the anatomy of the vaginal canal, cervix, and pelvic structures, such as those that occur after childbirth. After vaginal childbirth, the pelvic structures may undergo changes, including stretching and possible loss of tone. These changes can affect the fit and position of the diaphragm, leading to decreased contraceptive efficacy. Therefore, it's important for women who have given birth to have their diaphragm refitted by a healthcare provider before resuming its use.
Correct Answer is C
Explanation
A) Incorrect- While physical soothing can help comfort the child after the injections, it may not significantly reduce the duration of pain during the injections themselves.
B) Incorrect- Verbal reassurance is important to provide a calming environment, but it may not directly reduce the duration of pain during the injections.
C) Correct- Administering vaccines can be distressing for toddlers due to the pain associated with injections. To reduce the duration of pain and minimize the overall discomfort, the nurse should prioritize the strategy of simultaneous injections. This involves administering multiple vaccines at the same time rather than spacing them out. The rationale behind this approach is that the child experiences the discomfort of the injections only once, which can help reduce their overall distress and anxiety.
D) Incorrect- The positioning of the child may not have a direct impact on the duration of pain during injections. However, choosing an appropriate position for comfort is still important.
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