Giddens ch. 2 Functional ability
The nurse is assessing a patient's functional performance. What assessment parameters will be most important in this assessment? A. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment B. Height, weight, body mass index (BMI), vital signs assessment C. Sleep assessment, energy assessment, memory assessment, concentration assessment D. Healthy individual, volunteers at church, works part time, takes care of family and house
A Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.
The nurse is assessing a patient's functional abilities and asks the patient, "How would you rate your ability to prepare a balanced meal?" "How would you rate your ability to balance a checkbook?" "How would you rate your ability to keep track of your appointments?" Which tool would be indicated for the best results of this patient's perception of their abilities? A. Functional Activities Questionnaire (FAQ)™ B. Mini Mental Status Exam (MMSE) C. 24hFAQ D. Performance-based functional measurement
A The FAQ is an example of a self-report tool which provides information about the patient's perception of functional ability. The MMSE assesses cognitive impairment. The 24hFAQ is used to assess functional ability in postoperative patients. Performance-based tools involve actual observation of a standardized task, completion of which is judged by objective criteria.
The nurse is assessing a patient's ability to perform basic activities of daily living (BADLs). Which of the following activities are considered in the BADLs assessment? (Select all that apply.) A. Brushing teeth or dentures B. Dressing oneself in the mornings C. Washing, drying, and folding laundry D. Counting own pulse and taking heart pill E. Taking the bus to the park F. Calling family members
A, B BADLs include actions related to self care and mobility and also includes eating, personal hygiene, and grooming activities. Instrumental activities of daily living (IADLs) include shopping, meal preparation, housekeeping, doing laundry, managing finances, using the telephone, taking medications, and using transportation.
Which of the following interventions are priorities in a plan of care for a patient who had a stroke 30 days ago and is now in home care rehabilitation? (Select all that apply.) A. Promoting rest and sleep B. Promoting a diet rich in protein C. Promoting exercise and ambulation D. Assisting the patient with ADLs E. Limiting visitors and social contacts
A, C It is important to promote independence in ADLs early in the plan of care to increase independence in general. Promoting rest and sleep will promote well-being. Ambulation and exercise promote well-being and increase healing by circulating oxygen to the brain. Protein promotes healing in postsurgical patients but is not a main focus in stroke patients. Assisting the patient does not promote independence. Limiting visitors will isolate the patient, which can lead to depression.
The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate? A. "Are you able to shop for yourself?" B. "Do you use a cane, walker, or wheelchair to ambulate?" C. "Do you know what today's date is?" D. "Were you sad or depressed more than once in the last 3 days?"
B "Do you use a cane, walker, or wheelchair to ambulate?" will assist the nurse in determining the patient's ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.
Instruments such as the Functional Activities Questionnaire (FAQ) for postoperative patients who are at home, the Minimum Data Set for Nursing Facility Resident Assessment and Care Screening (MDS) for nursing home patients, the Functional Status Scale (FSS) for children, and the Edmonton Functional Assessment Tool for cancer patients are used to assess activities of daily living (ADLs). The nurse needs to remember that a disadvantage of these instruments includes: A. the measurement of efficacy and reliability of the instruments used to assess activities of daily living (ADLs). B. the variations in assessments and responses may be subjective because of self-reporting of functional activities. C. the instruments do not show a true measure of ability because of a lack of interactivity during the assessments. D. the information contained in the instruments is insufficient to make a determination about functional status in these populations.
B A disadvantage of many of the ADLs and instrumental activities of daily living (IADLs) instruments is the self-reporting of functional activities. Efficacy and reliability are not measured when assessing ADLs and IADLs. Interaction with the patient is necessary to complete the ADL and IADL assessments. The FAQ and FSS are comprehensive tools that can help the nurse determine functional status.
The nurse is assessing a patient's ability to perform instrumental activities of daily living (IADLs). Which of the following activities are considered in the IADLs assessment? (Select all that apply.) A. Feeding oneself B. Preparing a meal C. Balancing a checkbook D. Walking E. Toileting F. Grocery shopping
B, C, F IADLs include shopping, meal preparation, housekeeping, doing laundry, managing finances, taking medications, and using transportation. The other activities listed are activities of daily living (ADLs) related to self-care. IADLs are more complex skills that are essential to living in a community.
A 65-year-old female patient has been admitted to the medical/surgical unit. The nurse is assessing the patient's risk for falls so that falls prevention can be implemented if necessary. Select all the risk factors that apply from this patient's history and physical. (Select all that apply.) A. Being a woman B. Taking more than six medications C. Having hypertension D. Having cataracts E. Muscle strength 3/5 bilaterally F. Incontinence
B, D, E, F Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls. Men have a higher risk for falls. Hypertension itself does not contribute to falls. Dizziness does contribute to falls.
The home care nurse is trying to determine the necessary services for a 65-year-old patient who was admitted to the home care service status after left knee replacement. Which tool(s) will assist with this determination? A. Minimum Data Set (MDS) B. Functional Status Scale (FSS) C. 24-Hour Functional Ability Questionnaire (24hFAQ) D. The Edmonton Functional Assessment Tool
C The 24hFAQ assesses the postoperative patient in the home setting. The MDS is for nursing home patients. The FSS is for children. The Edmonton is for cancer patients.
The nurse is caring for an 85-year-old woman 6 weeks following a hysterectomy secondary to ovarian cancer. The patient will need chemotherapy and irradiation on an outpatient basis. The nurse should identify and address which barriers to healing? (Select all that apply.) A. Can feed herself and prepare meals but cannot drive to the store B. Lives on a fixed income and can balance her checkbook C. Experiences stress incontinence D. Cannot participate in activities at the senior center E. Lives alone and has no nearby relatives F. Has no transportation to the oncology clinic
C, E, F The patient will not be able to get treatment if she has no transportation or no relatives that live nearby who can help her with recovery. Stress incontinence increases the risk of falls because of urgency and rushing to get to the bathroom. Income and social abilities are lower priorities during this phase of recovery.
The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? A. Healthy individual, works outside the home, uses a cane, well groomed B. Healthy individual, college educated, travels frequently, can balance a checkbook C. Healthy individual, works out, reads well, cooks and cleans house D. Healthy individual, volunteers at church, works part time, takes care of family and house
D Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option.
The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient? A. Eating and drinking, personal cleansing and dressing, working and playing B. Toileting, transferring, dressing, and bathing activities C. Sleeping, expressing sexuality, socializing with peers D. Maintaining a safe environment, breathing, maintaining temperature
D The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient.