The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?
Request to have the client lie as still as possible for the assessment.
Ask the client how often episodes of sundowning are experienced.
Question the client about the frequency of falls in recent months.
Assist the client with clarifying values about end-of-life care
The Correct Answer is C
A) Incorrect - Requesting the client to lie still may be relevant for certain assessments, but it is not specific to the situation described in the question.
B) Incorrect - Inquiring about episodes of sundowning is more relevant for clients with cognitive impairment and is not directly related to the client's weight loss and decreased energy and appetite.
C) Correct - Questioning the client about the frequency of falls is important, as falls can contribute to weight loss, decreased energy, and appetite changes in older adults.
D) Incorrect - Assisting the client with clarifying values about end-of-life care is a valuable nursing intervention but is not the priority in this assessment scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A) Incorrect - Hyperglycemia typically does not lead to weight loss. In fact, it can result in weight gain due to the body's inability to properly use glucose for energy.
B) Correct - Hyperglycemia can lead to an increased sensation of hunger as the body's cells are not effectively receiving the glucose they need for energy, causing the person to feel hungry.
C) Incorrect - Cool and clammy skin are not typical symptoms of hyperglycemia. Hyperglycemia can lead to dry skin, but it does not cause cool and clammy skin.
D) Correct - Hyperglycemia often leads to increased thirst and urination. Excess glucose in the blood can cause the kidneys to work harder to filter and eliminate the glucose, leading to increased fluid intake and subsequently increased urination.
E) Hyperglycemia can cause dehydration, leading to dry, flushed skin and sometimes headaches due to electrolyte imbalances and reduced blood flow to the brain.
Correct Answer is B
Explanation
A) Incorrect- While bedtime monitoring is important, the frequency described in this choice is not consistent with FSBG monitoring before meals.
B) Correct- Performing FSBG monitoring before each meal helps the client track her blood glucose levels before consuming food, allowing her to adjust her diet or insulin regimen if necessary.
C) Incorrect- Monitoring every two hours may be excessive and not necessary for managing gestational diabetes.
D) Incorrect- Monitoring during the night is important for glycemic control, but it doesn't specifically address the need to monitor before meals.
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