Nokea
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 client's:
- A. Level of consciousness
- B. Ability to perform activities of daily living
- C. Degree of reasoning, judgment, and thought processes
- D. Level of functioning memory
Correct Answer: B
Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.
You may also like to solve these questions
An individual is brought by ambulance to the emergency room. The patient's roommate reports that the patient was weak and confused on awakening and began "rambling and talking crazy"Â about 3 hours ago. A nurse notes that the patient's skin is flushed and dry. When transferred to a bed, the patient strikes out at the staff and shouts, "You're not going to kill me!"Â The most likely analysis of this behavior is:
- A. disturbed self-esteem related to catastrophic reaction.
- B. disturbed sensory perception related to altered brain function.
- C. other-directed violence related to fear associated with hospitalization.
- D. impaired environmental interpretational syndrome related to metabolic disturbance.
Correct Answer: B
Rationale: The correct answer is B: disturbed sensory perception related to altered brain function. The patient's presenting symptoms of confusion, rambling speech, physical aggression, and paranoia suggest an altered mental state. The flushed and dry skin may indicate dehydration, which can affect brain function. The behavior is likely a result of the patient's distorted sensory perceptions due to an underlying physiological or neurological issue.
Incorrect choices:
A: disturbed self-esteem related to catastrophic reaction - This choice does not address the patient's specific symptoms and is not supported by the scenario.
C: other-directed violence related to fear associated with hospitalization - While fear of hospitalization may contribute to violence, it does not explain the patient's overall presentation of altered mental status.
D: impaired environmental interpretational syndrome related to metabolic disturbance - This choice does not directly address the patient's symptoms and does not explain the confusion and paranoia displayed.
A nurse is caring for a patient with anorexia nervosa who is refusing to eat. What should the nurse do first?
- A. Provide a structured meal plan and encourage the patient to eat.
- B. Avoid discussing food intake to reduce anxiety.
- C. Allow the patient to skip meals to avoid pressure.
- D. Offer incentives for eating a full meal.
Correct Answer: A
Rationale: The correct answer is A: Provide a structured meal plan and encourage the patient to eat. This is the first step because patients with anorexia nervosa often struggle with disordered eating behaviors and need guidance and support to establish healthy eating habits. Providing a structured meal plan helps the patient understand the importance of regular and balanced meals. Encouraging the patient to eat helps address their resistance and fear around food.
Incorrect choices:
B: Avoid discussing food intake to reduce anxiety - This choice is incorrect because avoiding discussing food intake does not address the underlying issue and may perpetuate the patient's disordered eating behavior.
C: Allow the patient to skip meals to avoid pressure - Allowing the patient to skip meals enables their unhealthy behavior and does not promote recovery.
D: Offer incentives for eating a full meal - While incentives may be used as a motivational tool, they do not address the core issue of establishing a healthy relationship with food.
The nurse at the clinic is interviewing a patient who offers a number of vague somatic complaints that might not ordinarily prompt a visit to a caregiver: fatigue, back pain, headaches, and sleep disturbance. The patient seems tense, and after having spoken of the symptoms, seems reluctant to provide more information and is in a hurry to leave. The nurse can best serve the patient by:
- A. Asking if the patient has ever had psychiatric counseling.
- B. Completing a structured abuse assessment protocol.
- C. Exploring the possibility of patient social isolation.
- D. Asking the patient to disrobe to check for signs of abuse.
Correct Answer: B
Rationale: The correct answer is B: Completing a structured abuse assessment protocol. Given the patient's vague complaints, tension, reluctance to provide more information, and hurry to leave, these could be signs of potential abuse. Completing a structured abuse assessment protocol allows the nurse to systematically assess for any signs of abuse, which could be contributing to the patient's somatic complaints. This approach is necessary to ensure the patient's safety and well-being.
Incorrect choices:
A: Asking if the patient has ever had psychiatric counseling - This choice does not directly address the potential abuse concerns indicated by the patient's behavior.
C: Exploring the possibility of patient social isolation - While social isolation could be a contributing factor, the urgency to leave and reluctance to provide information are more indicative of potential abuse.
D: Asking the patient to disrobe to check for signs of abuse - This choice is invasive and inappropriate without first completing a structured abuse assessment protocol to determine if abuse is likely.
An 85-year-old client with dementia has a nursing diagnosis of Self-care deficit: bathing, hygiene. She lives at home and has not bathed for a month. Her 67-year-old daughter states that she thinks her mother may have forgotten how to take a shower. An appropriate outcome would be that the client will:
- A. Bathe daily with reminders
- B. Bathe twice weekly with assistance
- C. Allow the nurse to totally manage hygiene
- D. Remain free of skin diseases/lesions
Correct Answer: B
Rationale: The correct answer is B: Bathe twice weekly with assistance. This outcome is appropriate because it takes into account the client's dementia and self-care deficit while also promoting hygiene and independence. Daily bathing may be overwhelming for the client and may not be necessary for maintaining good hygiene. Allowing the nurse to totally manage hygiene (choice C) may not promote the client's independence. Remaining free of skin diseases/lesions (choice D) is important but may not directly address the self-care deficit. Bathe twice weekly with assistance strikes a balance between promoting hygiene and respecting the client's abilities and limitations.
A catatonic patient admitted in a stuporous condition begins to demonstrate increased motor activity. During his assessment, the psychiatrist raises the patient's arm above his head and releases it. The patient maintains the position his arm was placed in, immobile in that position for 15 minutes, moving only when the nurse gently lowers his arm. What symptom is demonstrated by this assessment technique?
- A. Echopraxia
- B. Waxy flexibility
- C. Depersonalization
- D. Thought withdrawal
Correct Answer: B
Rationale: Waxy flexibility involves maintaining a posture imposed by another person, as seen in the patient's arm staying raised. This behavior is indicative of catatonia, a symptom of severe mental illness. Echopraxia involves mimicking movements of others, not maintaining a position. Depersonalization is a feeling of detachment from oneself, not related to physical movements. Thought withdrawal pertains to a symptom in schizophrenia where thoughts are removed by an external force, not related to physical posture.