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: Apply a pulse oximeter to the foot. Continuous monitoring of oxygen saturation can help detect hypoxemia early, which can be a concern in post-term infants due to potential respiratory distress or meconium aspiration. However, while important, this is a monitoring measure and not an immediate corrective action for potential metabolic or respiratory issues directly associated with post-term birth.

B: Draw arterial blood gases. Arterial blood gases (ABGs) provide critical information about the newborn's acid-base balance, oxygenation, and ventilation status. Post-term infants are at risk for hypoxia and acidosis, often due to placental insufficiency or meconium aspiration. However, obtaining ABGs can be invasive and might not be the first-line immediate action unless there are signs of severe distress.

C: Obtain a capillary blood glucose. Post-term infants are at increased risk for hypoglycaemia due to increased glucose utilization and possible depletion of glycogen stores. Hypoglycaemia can lead to serious complications if not promptly identified and managed. Therefore, checking blood glucose levels is a critical, non-invasive, and immediate step to ensure metabolic stability and prevent complications such as seizures and brain injury.

D: Provide blow-by oxygen. Blow-by oxygen is used to provide supplemental oxygen in a non-invasive manner and can help in cases of mild respiratory distress. Post-term infants can be at risk for respiratory issues, including meconium aspiration syndrome. However, this is usually applied when there is evidence of respiratory distress and not as a routine measure without specific indications.

A. Eats less salt-cured meats. B. Participates in healing rituals. C. Uses herbal remedies. D. Meditates in sweat lodges.

Correct Answer is C

Explanation

A. Eats less salt-cured meats: Reducing the intake of salt-cured meats is generally a positive behaviour, especially for someone with hypertension. This behaviour aligns with dietary recommendations for managing high blood pressure.

B. Participates in healing rituals: Healing rituals are part of many cultural practices and can provide emotional and spiritual support. However, without further information, it's unclear if these rituals interfere with the prescribed treatment. This may warrant additional assessment to ensure they complement the medical regimen.

C. Uses herbal remedies: The use of herbal remedies could potentially interact with prescribed antihypertensive medications. This behaviour requires careful assessment to ensure there are no harmful interactions or adverse effects on the treatment plan.

D. Meditates in sweat lodges: Sweat lodges are a traditional practice for many Native Americans, providing physical and spiritual cleansing. However, the high temperatures and dehydration risks associated with sweat lodges could adversely affect blood pressure control and overall cardiovascular health. This behaviour requires further evaluation to ensure it is safe for the client with hypertension.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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