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.

Answer and Explanation

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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Correct Answer is ["9"]

Explanation

Here are the steps you can follow to calculate the infusion pump flow rate:

Step 1: Calculate the prescribed dose in mcg/min

Dose per weight: 2 mcg/kg/min * 60 kg = 120 mcg/min

Step 2: Convert the concentration in the IV bag to mcg/mL

Convert mg to mcg: 200 mg * 1000 mcg/mg = 200,000 mcg
Concentration: 200,000 mcg / 250 mL = 800 mcg/mL

Step 3: Calculate the flow rate in mL/min

Flow rate: 120 mcg/min / 800 mcg/mL = 0.15 mL/min

Step 4: Convert the flow rate to mL/hour

Hour conversion: 0.15 mL/min * 60 min/hour = 9 mL/hour

Therefore, the nurse should program the infusion pump to deliver 9 mL/hour.

A. Anxiety as evidenced by abdominal complaints secondary to depression. B. Imbalanced nutrition as evidenced by 25 pound (11 kg) weight loss in four months. C. Chronic low self-esteem as evidenced by feelings of worthlessness. D. Risk for self-directed violence as evidenced by feelings of hopelessness.

Correct Answer is D

Explanation

The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.

Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.

The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.

While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.

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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?

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes dopamine 2 mcg/kg/min intravenously (IV) for client who weighs 60 kg. The IV bag contains dopamine 200 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

Correct Answer is ["9"]

Explanation

Correct Answer is D

Explanation

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