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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The whispered voice test is used to assess the function of Cranial Nerve VIII, which is responsible for hearing and balance. The nurse's whisper tests the auditory function of this nerve.
B. The vagus nerve is involved in swallowing, voice production, and parasympathetic functions but is not assessed by whispering.
C. This nerve controls lateral eye movement, and a whispered voice test does not assess eye movement.
D. This nerve also controls eye movement, specifically the superior oblique muscle, and is not evaluated by the whispered voice test.
Correct Answer is A
Explanation
A. Palpation should be done after auscultation to avoid altering the bowel sounds. Palpation can cause changes in the sounds, making it difficult to assess accurately.
B. It is advisable to auscultate bowel sounds when the patient is not actively eating, so this action is appropriate.
C. This is the correct duration for assessing bowel sounds. Auscultating for 3-5 minutes is within the standard practice.
D. If the client has an NG tube, clamping it before auscultation is appropriate as it prevents additional noises or interference from the tube.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.