The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the
level of consciousness.
ability to perform activities of daily living
degree of reasoning, judgment, and thought processes.
level of functioning memory
The Correct Answer is B
A. It is typically part of a neurological or mental status examination rather than a functional assessment. Functional assessments are more concerned with how well a client can manage daily tasks and their overall ability to live independently.
B. The primary purpose of a functional assessment is to determine the client’s ability to perform activities of daily living (ADLs). ADLs include tasks such as bathing, dressing, grooming, eating, toileting, and mobility. This assessment helps to identify areas where the client may need assistance and guides the development of a care plan to support their independence and quality of life.
C. While assessing cognitive functions such as reasoning, judgment, and thought processes can be part of a comprehensive evaluation, it is not the primary goal of a functional assessment. These cognitive aspects are more relevant in mental status examinations or neuropsychological assessments.
D. Assessing memory is important for understanding cognitive function, but it is not the main focus of a functional assessment. Functional assessments are centered around evaluating practical abilities related to daily living rather than specific cognitive functions like memory.
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Related Questions
Correct Answer is C
Explanation
A. During escalation, individuals are experiencing increasing tension and anger but may still be able to respond to reason or directions. This is the stage where intervention is crucial to prevent the situation from worsening.
B. This phase follows the crisis and is characterized by a decrease in tension. Individuals may be more receptive to communication and reasoning at this point.
C. This is the stage where individuals have lost control, and their behavior is driven by intense emotions. They are unable to process information or respond rationally.
D. The trigger is the initial event that sets off the cycle. While it can lead to escalating emotions, it doesn't necessarily prevent individuals from listening or engaging mentally.
Correct Answer is A
Explanation
A. It’s important for a nurse to address the behavior immediately and to establish expectations for acceptable conduct. However, while this statement is firm, it does not offer immediate guidance or intervention on how to resolve the situation or manage emotions.
B. This statement is not appropriate in this context because it incorrectly assumes the behavior was physical (hitting) rather than verbal (yelling). It also places the client on the defensive and may not
effectively address the immediate situation. Instead of focusing on why the behavior occurred, it’s more
important to manage and de-escalate the current situation first.
C. This response is punitive and does not address the immediate issue or the underlying causes of the behavior. While setting consequences may be part of a broader behavior management plan, immediate actions should focus on de-escalation and safety rather than punishment. Additionally, consequences should be proportionate and ideally involve a discussion with the client about their behavior and its impact.
D. This statement is not effective because it shifts the focus from the immediate behavior to a vague notion of disappointment, which may not address the situation constructively. It’s important for the nurse to be clear about the expectations for behavior and to provide immediate guidance on managing emotions and conflicts.
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