The client is scheduled for a functional assessment using the Functional Independence Measure (FIM). The client asks the nurse, "What is the
purpose of the FIM?" Which nursing response is appropriate?
"It is a tool that is used to determine your maximum level of self-sufficiency.”
"It is a test that determines which activities you feel most comfortable performinG.”
"It is a tool used by insurance companies to determine qualifications for medical reimbursement."
"It is a tool that is used to assess what services you will need a home health aide to perform for you."
The Correct Answer is A
Choice A reason: "It is a tool that is used to determine your maximum level of self-sufficiency.” This nursing response is appropriate because it accurately describes the purpose of the FIM, which is a standardized instrument that measures the client's level of independence in performing 18 activities of daily living and mobility tasks.
Choice B reason: "It is a test that determines which activities you feel most comfortable performinG.” This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a test that measures the client's comfort level, but rather their functional ability.
Choice C reason: "It is a tool used by insurance companies to determine qualifications for medical reimbursement." This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a tool that determines the client's eligibility for insurance coverage, but rather their functional status and progress.
Choice D reason: "It is a tool that is used to assess what services you will need a home health aide to perform for you." This nursing response is not appropriate because it does not describe the purpose of the FIM, which is not a tool that evaluates the client's need for home care services, but rather their functional capacity and improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Hypertension is a manifestation of increased intracranial pressure because it is part of the Cushing's triad, which is a set of signs that indicate increased intracranial pressure and impaired cerebral perfusion. The other signs of Cushing's triad are bradycardia and irregular respirations.
Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure because it is a symptom of hearing loss, ear infection, or ear damage, not increased intracranial pressurE. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors such as exposure to loud noise, aging, or medication side effects.
Choice C reason: Hypotension is not a manifestation of increased intracranial pressure because it is a sign of decreased blood pressure, not increased intracranial pressurE. Hypotension can be caused by various factors such as dehydration, blood loss, or shock.
Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure because it is a sign of increased heart rate, not increased intracranial pressurE. Tachycardia can be caused by various factors such as anxiety, fever, or pain.
Correct Answer is C
Explanation
- An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution³.
- The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work⁴.
- The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions³⁴.
Option A is incorrect because the client’s comfort level may not reflect the optimal temperature for the
enema.
Option B is incorrect because the temperature of the enema does affect its effectiveness and safety. Option D is incorrect because the temperature is too high and can cause harm to the client.
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