The nurse is obtaining a history from a patient reference activity. Which of the following should be included? Select all that apply.
Immunization record
Daily activity level
Patient's response after the activity or exercise
Problems with mobility or exercise
External factors affecting mobility
Correct Answer : B,C,D,E
A. Immunization record: While important for overall health, the immunization record is less directly related to current activity levels and exercise.
B. Daily activity level: This provides important information about the patient's current physical activity, which is relevant for assessing overall health and mobility.
C. Patient's response after the activity or exercise: Understanding how the patient responds after activity helps assess the impact of exercise on their health and mobility.
D. Problems with mobility or exercise: Identifying any problems with mobility or exercise helps in tailoring the patient’s activity plan and addressing any issues related to physical function.
E. External factors affecting mobility: External factors, such as environmental barriers or equipment, can significantly impact the patient’s mobility and should be considered in the assessment.
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Related Questions
Correct Answer is B
Explanation
A. Gait belt with handles: A gait belt can provide support and stability during transfers, but it is generally used for walking rather than transferring directly from bed to chair.
B. Lateral-assist transfer board: A lateral-assist transfer board can help with moving the patient from bed to chair by sliding, making it appropriate for this transfer scenario.
C. Powered stand-assist aid: A powered stand-assist aid is typically used to help patients who need assistance standing and could be appropriate if the patient requires more support during the transfer.
D. Powered full-body lift: A powered full-body lift is generally used for patients who cannot bear weight at all and would not be necessary for a patient who can bear weight on one leg and use a walker.
Correct Answer is D
Explanation
A. Decrease in muscle mass and strength: A decrease in muscle mass and strength is common with aging, known as sarcopenia. While it should be monitored, it is not necessarily an abnormal finding requiring further investigation unless it is severe or sudden.
B. Lower back and neck pain: Lower back and neck pain can be common with aging due to degenerative changes in the spine or other musculoskeletal issues. However, persistent or severe pain should be evaluated to rule out other causes.
C. Wrinkling and sagging skin: Wrinkling and sagging skin are normal aging changes related to decreased collagen and elastin in the skin. These changes are generally expected with aging.
D. Joint stiffness in fingers: Joint stiffness can be related to aging but may also indicate conditions like arthritis. If the stiffness is significant, persistent, or accompanied by other symptoms, it requires further investigation.
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