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 A

Explanation

A. Inspection. Papilledema, swelling of the optic disc due to increased intracranial pressure, is primarily assessed through inspection of the optic disc using an ophthalmoscope. The nurse would look for optic disc swelling and blurred disc margins.

B. Auscultation. Auscultation is not appropriate for assessing papilledema, as it involves listening for sounds such as heart, lung, or bowel sounds.

C. Palpation. Palpation is not appropriate for assessing papilledema, as it involves touching and feeling for abnormalities, which would not be possible with the optic disc.

D. Percussion. Percussion is not appropriate for assessing papilledema, as it involves tapping the body surface to elicit sounds or vibrations, which would not provide information about the optic disc.

A. Ask questions in a vague, nonspecific format. B. Share personal values to put the client at ease. C. Get the most difficult questions over with first. D. Begin with questions that are less sensitive in nature.

Correct Answer is D

Explanation

A. Ask questions in a vague, nonspecific format: Vague questions won't elicit clear answers.

B. Share personal values to put the client at ease: While building rapport is important, sharing personal values might not be necessary.

C. Get the most difficult questions over with first: This can make the client defensive and less likely to be honest.

D. Begin with less sensitive questions: Starting with general questions about lifestyle habits and then gradually transitioning to more specific questions about alcohol and substance use can create a more comfortable environment for open communication

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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

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Correct Answer is A

Explanation

Which is the best approach for the nurse to use when interviewing a client about alcohol and substance use?

Correct Answer is D

Explanation

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