The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Ask the client how often episodes of sun downing are experienced.

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

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

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

Answer and Explanation

The Correct Answer is C

A.   Sundowning refers to confusion and agitation that typically occurs in the late afternoon or evening in some individuals with dementia or other cognitive impairments. While important for understanding the client’s cognitive and behavioral patterns, this question is more specific to cognitive or behavioral issues rather than directly assessing functional abilities.
B.   Values clarification regarding end-of-life care is crucial, especially for advanced planning and ensuring that care aligns with the client’s preferences. However, this is typically part of a different type of discussion and planning, rather than a general functional assessment.
C.   Inquiring about recent falls is a relevant component of a functional assessment. Falls can indicate issues with mobility, balance, strength, or cognitive function, all of which are critical for assessing a client's need for nursing home care. Understanding the frequency and circumstances of falls helps in evaluating the client's overall safety and functional status, which is essential for planning appropriate care.
D.   Asking the client to lie still is not typically relevant or necessary for a functional assessment, which
generally involves evaluating the client’s ability to perform activities of daily living (ADLs), mobility, and overall function. A functional assessment often involves observing the client’s movement, activities, and responses, which requires them to be active and engaged rather than lying still.

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Correct Answer is D

Explanation

A. While medical diagnoses can influence the type of care a client needs, functional capacity is the most important factor when determining the best living environment.
B. Age and gender can be factors to consider, but they are not as important as functional capacity. For example, an older adult with a high level of functional independence may be able to live independently, even if they are elderly.
C. This is not relevant to the decision of where an older adult client should live.
D. The client's functional capacity is the most important factor to consider when determining the best living environment. If the client requires significant assistance with ADLs, a nursing home or assisted living facility may be the most appropriate option.

A. Over the cheeks. B. Around the nostrils. C. Across the forehead. D. Bridge of the nose. E. Tops of the ears.

Correct Answer is ["A","B","D","E"]

Explanation

A. The cheeks can be affected by the nasal cannula, especially if it is not positioned properly or if it causes irritation over time.
B. The area around the nostrils is one of the most common sites for skin damage related to nasal cannulas. Continuous contact with the cannula can cause irritation, redness, or even sores in this area.
C. The nasal cannula itself does not typically make contact with the forehead. Therefore, skin damage across the forehead is not generally a concern related to the use of a nasal cannula.
D. The bridge of the nose is a key area to inspect for skin damage. The nasal cannula’s prongs often rest on or near the bridge of the nose, which can lead to pressure sores, redness, or irritation in this area. Regular assessment is important to prevent and address any damage.
E. The tops of the ears can be affected if the nasal cannula’s tubing or securing mechanism (such as behind-the-ear supports or loops) causes friction or pressure. Skin breakdown can occur in this area if the cannula is not properly adjusted or if it causes irritation.

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The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

Correct Answer is D

Explanation

The nurse assesses a client who has a nasal cannula delivering oxygen at 2 liters/minute. To assess for skin damage related to the cannula, what areas should the nurse observe? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

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