Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

Telephoning a family member.

Opening a bar soap package.

Sorting a collection of socks.

Reading a short paragraph.

Answer and Explanation

The Correct Answer is B

Answer: B. Opening a bar soap package.

Rationale:

A) Telephoning a family member:
Using a telephone is considered an instrumental activity of daily living (IADL), which involves more complex tasks required for independent living, such as managing communication. While important, it does not directly assess the physical and motor skills required for basic self-care.

B) Opening a bar soap package:
Opening a bar soap package involves fine motor skills and hand coordination, which are necessary for performing basic activities of daily living (ADLs). ADLs refer to essential self-care tasks like bathing, dressing, and grooming. Being able to open soap indicates the client has the dexterity needed for personal hygiene.

C) Sorting a collection of socks:
Sorting socks is more cognitive than motor-oriented, and it assesses organization skills, which are more aligned with IADLs rather than ADLs. It does not specifically evaluate the client’s ability to perform tasks related to basic self-care.

D) Reading a short paragraph:
Reading a paragraph evaluates literacy or cognitive function but is not directly related to performing ADLs. ADLs focus on physical activities necessary for daily living, such as dressing, eating, or bathing.

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Correct Answer is C

Explanation

A) Diabetes mellitus: While diabetes can lead to various complications affecting the nails, such as yellowing or thickening due to poor circulation and infections, it is not typically associated with brittle, concave (spoon-shaped) nails.

B) Recent candida infection: Candida infections can affect the nails, causing them to become discolored, thickened, or separated from the nail bed, but they do not typically cause the nails to become brittle and concave.

C) Iron deficiency anemia: This condition is often associated with brittle, spoon-shaped (concave) nails, known as koilonychia. Iron deficiency anemia affects the oxygen-carrying capacity of the blood, which can lead to changes in the nail beds, making them appear concave and brittle.

D) Coronary heart disease: While coronary heart disease can lead to changes in the nails due to poor circulation, it is not commonly associated with the specific finding of brittle, concave nails. Other nail changes might include clubbing or cyanosis, but not typically koilonychia.

A. Face is flushed and diaphoretic. B. Eyelids are matted and crusted. C. Cornea are jaundiced. D. Oral mucosa is cyanotic.

Correct Answer is D

Explanation

A) Face is flushed and diaphoretic:
While flushing and diaphoresis can indicate fever, anxiety, or other conditions, they do not typically require immediate intervention unless associated with other severe symptoms.

B) Eyelids are matted and crusted:
Matted and crusted eyelids may indicate an eye infection, such as conjunctivitis, which requires treatment but not immediate emergency intervention.

C) Cornea are jaundiced:
Jaundiced corneas (scleral icterus) suggest elevated bilirubin levels and possible liver dysfunction. This finding requires prompt evaluation but is not typically an emergency requiring immediate intervention.

D) Oral mucosa is cyanotic:
Cyanosis of the oral mucosa indicates a lack of oxygen in the blood and is a sign of hypoxemia or respiratory distress. This is a critical finding that requires immediate intervention to address potential life-threatening respiratory or cardiovascular issues.

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Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

Rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

Correct Answer is C

Explanation

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

Correct Answer is D

Explanation

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?