The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.
Which action should the nurse include during the assessment?

Ask the patient how often episodes of sundowning are experienced.

Inquire about the frequency of falls in recent months.

Request the patient to lie as still as possible for the assessment.

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

Answer and Explanation

The Correct Answer is B

Choice A rationale

Asking the patient how often episodes of sundowning are experienced is more relevant in assessing cognitive function, particularly in patients with dementia. It is not directly related to the patient’s weight loss or decreased energy and appetite.

Choice B rationale

Inquiring about the frequency of falls in recent months is crucial in a functional assessment of an older patient who has lost weight and reports a decrease in energy and appetite. Weight loss and decreased energy can increase the risk of falls, which can lead to serious injuries and further functional decline.

Choice C rationale

Requesting the patient to lie as still as possible for the assessment is not directly related to the patient’s weight loss or decreased energy and appetite. It might be necessary for certain physical examinations or procedures, but it is not the most relevant action in this context.

Choice D rationale

Assisting the patient with clarifying values about end-of-life care options is an important aspect of geriatric care, especially in patients with serious illnesses. However, it is not directly related to the patient’s weight loss or decreased energy and appetite.

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Free Nursing Study Resources

Correct Answer is ["C","D","E","F","G","H","J"]

Explanation

Based on the provided information, the following assessment findings require immediate follow-up by the nurse:

Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
The client is pale: Paleness can be a sign of decreased oxygenation.
Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.

Correct Answer is ["1.32"]

Explanation

Step 1 is to convert the patient’s weight from pounds to kilograms. There are approximately 2.2046 pounds in 1 kilogram. So, the patient’s weight in kilograms is 132 lb ÷ 2.2046 = 59.87 kg.

Step 2 is to calculate the total dose of lorazepam the patient should receive. The prescribed dose is 44 mcg/kg. So, the total dose in micrograms is 44 mcg/kg × 59.87 kg = 2634.28 mcg.

Step 3 is to convert the total dose from micrograms to milligrams. There are 1000 micrograms in 1 milligram. So, the total dose in milligrams is 2634.28 mcg ÷ 1000 = 2.63428 mg.

Step 4 is to calculate the volume of lorazepam solution to administer. The concentration of the solution is 2 mg/mL. So, the volume in milliliters is 2.63428 mg ÷ 2 mg/mL = 1.31714 mL. Therefore, the nurse should administer approximately 1.32 mL of the lorazepam solution, rounding to the nearest hundredth as required.

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The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.Which action should the nurse include during the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["C","D","E","F","G","H","J"]

Explanation

A patient weighing 132 lb is prescribed lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in a 2 mg/mL vial. How many mL should the nurse administer? Round off to 2 d.p. (This is a medical math nd does not require options.)

Correct Answer is ["1.32"]

Explanation

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The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.
Which action should the nurse include during the assessment?