The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?
Assess for spinal scoliosis.
Compare shoulder symmetry.
Observe gait while walking.
Palpate for joint nodules.
The Correct Answer is C
A. Assess for spinal scoliosis: While scoliosis can affect posture and mobility, it is less likely to immediately impact the client’s safety in performing daily activities at home.
B. Compare shoulder symmetry: Shoulder asymmetry may indicate musculoskeletal issues but is not the most critical factor in evaluating fall risk or functional independence.
C. Observe gait while walking: Gait assessment provides direct information about balance, coordination, and mobility, which are key indicators of fall risk and home safety. Observing how the client walks helps the nurse plan interventions to prevent injury.
D. Palpate for joint nodules: Detecting nodules can identify conditions such as osteoarthritis, but the presence of nodules alone does not provide immediate insight into functional mobility or home safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. Fever greater than 101.5° F (38.6° C): Fever may indicate infection, such as meningitis or shunt infection, but it is not a primary sign of increased intracranial pressure (ICP) in infants.
B. Decreased urinary output: Oliguria is not a typical early sign of increased ICP. While it can occur with severe systemic compromise, it is not a direct indicator of ICP changes.
C. Sunsetting eyes: The “sunsetting” sign, where the eyes appear driven downward with the sclera visible above the iris, is a classic indicator of increased ICP in infants due to hydrocephalus and should be closely monitored.
D. Bulging anterior fontanel: A bulging anterior fontanel reflects increased pressure within the cranial vault and is a key early sign of increased ICP in infants.
E. Jugular venous distension: Jugular venous distension is more indicative of cardiac or fluid overload issues rather than increased ICP in infants.
Correct Answer is C
Explanation
A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.
B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.
C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.
D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.
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