The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

Question the client about the frequency of falls in recent months.

Request to have the client lie as still as possible for the assessment.

Assist the client with clarifying values about end-of-life care options.

Ask the client how often episodes of sundowning are experienced.

Answer and Explanation

The Correct Answer is A

A. Question the client about the frequency of falls in recent months: Falls are a common concern in older adults. Assessing the frequency of falls helps identify potential safety risks and mobility issues. It provides valuable information about the client’s functional status and balance.

B. Request to have the client lie as still as possible for the assessment: While assessing functional status, it is essential to observe the client’s mobility and ability to perform activities of daily living (ADLs). Having the client lie still would not provide relevant information about their functional abilities.

C. Assist the client with clarifying values about end-of-life care options: While discussing end-of-life care is important, it is not directly related to assessing functional status. This action is beyond the scope of a functional assessment.

D. Ask the client how often episodes of sundowning are experienced: Sundowning refers to increased confusion, agitation, or behavioural changes in older adults during the late afternoon or evening. While relevant to overall well-being, it is not specifically related to functional assessment.

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Correct Answer is C

Explanation

A. Open-ended question. This response is not an open-ended question. Open-ended questions typically invite the client to share more information or elaborate on their thoughts and feelings. Instead, the nurse's response acknowledges the client's feelings and demonstrates empathy without directly soliciting more information.

B. Clarification. This response is not clarification. Clarification involves seeking clarification or additional information to ensure understanding. The nurse's response does not seek clarification but rather acknowledges the client's emotions.

C. Empathizing. This response is empathizing. Empathizing involves recognizing and understanding the client's emotions and expressing empathy. The nurse's response acknowledges the client's difficult situation and validates their feelings of distress, demonstrating empathy and understanding.

D. Paraphrasing. This response is not paraphrasing. Paraphrasing involves restating the client's message in the nurse's own words to confirm understanding. The nurse's response does not restate the client's message but rather expresses empathy and validation of the client's emotions.

A. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. B. Looking at the client from the side, observe the size and shape of the chest wall. C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.

Correct Answer is C

Explanation

A. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. This action is used to assess breath sounds, not tactile fremitus.

B. Looking at the client from the side, observe the size and shape of the chest wall. This action helps in assessing the general appearance and shape of the chest but does not assess tactile fremitus.

C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. This is the correct technique to assess tactile fremitus. Increased fremitus can indicate consolidation, as in pneumonia.

D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. This action is associated with palpating for crepitus, not assessing tactile fremitus.

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The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is C

Explanation

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