The nurse is preparing to perform a functional assessment of an older patient. What is an appropriate approach for the nurse to take?

Review the medical record for information on the patient's abilities.

Ask the patient's wife how he does when performing tasks.

Ask the patient's physician for information on the patient's abilities.

Observe the patient's ability to perform the tasks.

Answer and Explanation

The Correct Answer is D

A.   Although the medical record can provide background information, it does not give the real-time assessment of the patient's current functional abilities.
B.   While this information can be valuable, observing the patient directly provides the most accurate assessment of his abilities.
C.   The physician’s perspective is important but may not fully capture the patient's day-to-day functional capacity.
D.   Direct observation allows the nurse to assess the patient’s current functional status and make necessary adjustments to the care plan.

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Correct Answer is B

Explanation

A. Muscle atrophy, which typically occurs in older adults, may actually reduce BMI, not increase it, because muscle mass decreases with age.
B. Height may decrease due to changes in bone density. As people age, bone density decreases, and the vertebrae can compress, leading to a loss in height. This is a common occurrence in older adults.
C. Increased skin elasticity will affect the waist-hip ratio. Skin elasticity does not directly affect the waistto-hip ratio. The waist-to-hip ratio is more related to fat distribution than to skin elasticity.
D. Increased muscle mass will affect the mid-arm circumference measurements. Older adults typically experience muscle loss, not an increase in muscle mass, so this statement would not be accurate for an elderly client.

A. Bone spur B. Crepitation C. Loose tendon D. Fluid in the knee joint

Correct Answer is B

Explanation

A. A bone spur typically does not cause crunching or grating sounds and is not usually associated with morning stiffness.
B. Crepitation is the medical term for a grating or crunching sound often caused by joint issues, such as osteoarthritis, which could be the cause of the symptoms described.
C. A loose tendon would not typically cause a crunching or grating sound.
D. Fluid accumulation in the knee (effusion) would likely cause swelling and pain, but it would not typically produce a grating sound

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The nurse is preparing to perform a functional assessment of an older patient. What is an appropriate approach for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse needs to obtain anthropometric measures of an 80-year-old client. Which of the following statements is true regarding this situation?

Correct Answer is B

Explanation

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

Correct Answer is B

Explanation

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During a cardiovascular assessment of an 80-year-old adult, a nurse should consider which of the following as expected findings?

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