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A home care nurse assesses an older client's functional status and ability to perform activities of daily living (ADLs). What is the focus area of the nurse's assessment?
- A. Everyday routines
- B. Self-care activities
- C. Household management
- D. Endurance and flexibility
Correct Answer: B
Rationale: To evaluate the client's functional status, the nurse assesses the client's ability to perform self-care or ADLs, including bathing, toileting, ambulating, dressing, and feeding. Everyday routines, household management, and physical condition are not components of functional status.
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The nurse prepares to administer a continuous intravenous (IV) infusion through a peripheral IV to a dehydrated client. Which priority assessment should the nurse obtain before initiating the IV infusion?
- A. Daily body weight
- B. Serum electrolytes
- C. Intake and output records
- D. Identifying the client's dominant side
Correct Answer: A
Rationale: The nurse obtains the client's baseline body weight as a priority before beginning the IV infusion because body weight is a sensitive and specific indicator of fluid volume status when body weights are compared on a daily basis. This means that as a client receives or accumulates fluid, body weight quickly and proportionately increases and vice versa. The remaining options may also be reasonable assessments to complete before initiating an IV infusion. However, intake, output, and serum electrolytes are potentially affected by more confounding factors; thus, they are less specific and sensitive to fluctuations in body fluid. Determining the client's dominant side assists in deciding a site for inserting the initial IV catheter, but it provides no information about fluid volume status.
A client at 35 weeks of gestation reports a sudden discharge of fluid from the vagina. Based on the data provided, which condition should the nurse suspect?
- A. Miscarriage
- B. Preterm labor
- C. Intrauterine fetal demise
- D. Premature rupture of the membranes
Correct Answer: D
Rationale: Premature rupture of the membranes is usually manifested by a sudden discharge of fluid from the vagina before 37 weeks of gestation. Miscarriage is typically manifested by vaginal bleeding and abdominal pain. Preterm labor is typically manifested by uterine contractions, cramping, and pressure before 37 weeks of gestation. Intrauterine fetal demise is usually manifested by an absence of fetal movements and heartbeat.
A client in a long-term care facility has had a series of gastrointestinal (GI) diagnostic tests, including an upper and lower GI series and endoscopies. Upon return to the long-term care facility, which priority assessment should the nurse focus on?
- A. The comfort level
- B. Activity tolerance
- C. The level of consciousness
- D. The hydration and nutrition status
Correct Answer: D
Rationale: Many of the diagnostic studies to identify GI disorders require that the GI tract be cleaned (usually with laxatives and enemas) before testing. In addition, the client most often takes nothing by mouth before and during the testing period. Because the studies may be done over a period that exceeds 24 hours, the client may become dehydrated and/or malnourished. Although the remaining options may be components of the assessment, the correct option is the priority.
Which aspect should the nurse focus on when assessing a client for the vegetative signs of depression? Select all that apply.
- A. Weight
- B. Appetite
- C. Sleep patterns
- D. Suicidal ideations
- E. Psychomotor activity
- F. Rational decision making
Correct Answer: A,B,C,E
Rationale: The vegetative signs of depression are changes in physiological functioning that occur during depression. These include changes in appetite, weight, sleep patterns, and psychomotor activity. The remaining options represent psychological assessment categories.
A client prescribed dextroamphetamine reports to the nurse difficulty falling asleep at night. The nurse instructs the client on how to minimize sleep disorders. Which statement by the client indicates that teaching has been effective?
- A. I'll take the medication with a bedtime snack.
- B. I'll take the medication upon awaking in the morning.
- C. I'll take the medication two hours before going to bed.
- D. I'll take the medication at least 6 hours before bedtime.
Correct Answer: D
Rationale: Dextroamphetamine is a central nervous system (CNS) stimulant that acts by releasing norepinephrine from the nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep. Therefore, the remaining options are incorrect.