Jarvis-Ch. 32: Functional Assessment of the Older Adult

5. The nurse is assessing an older adult's advanced activities of daily living, which would include: A. Recreational activities. B. Meal preparation. C. Balancing the checkbook. D. Self-grooming activities.

ANS: A Advanced activities of daily living (AADL) are activities that an older adult performs such as occupational and recreational activities. Self-grooming activities are basic activities of daily living (ADLs); meal preparation and balancing the checkbook are considered instrumental activities of daily living (IADLs)

10. An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: A. Depression. B. Weight gain. C. Hypertension. D. Social phobias

ANS: A Caregiver burden is the perceived strain by the person who cares for an elderly, chronically ill, or disabled person. Caregiver burnout is linked to the caregiver's ability to cope and handle stress. Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss. Screening caregivers for depression may also be appropriate.

8. A patient will be ready to be discharged from the hospital soon, and the patient's family membersare concerned about whether the patient is able to walk outside alone safely. The nurse will perform which test to assess this? A. The Get Up and Go Test B. The Performance Activities of Daily Living C. The Physical Performance Test D. Tinetti Gait and Balance Evaluation

ANS: A The Get Up and Go Test is a reliable and valid test to quantify functional mobility. The test is quick, requires little training and no special equipment, and is appropriate to use in many settingsincluding hospitals and clinics. This instrument has been shown to predict a person's ability to gooutside alone safely. The Performance of Activities of Daily Living test has a trained observer actually observing as a patient performs various ADLs. The Physical Performance Test assesses upper body fine motor and coarse motor activities, as well as balance, mobility, coordination, andendurance. The Tinetti Gait and Balance Evaluation assesses gait and balance and provides information about fall risk

2. The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: A. Observe the patient's ability to perform the tasks. B. Ask the patient's wife how he does when performing tasks. C. Review the medical record for information on the patient's abilities. D. Ask the patient's physician for information on the patient's abilities.

ANS: A There are two approaches for performing a functional assessment, asking individuals about their abilities to perform the tasks (using self-reports) or actually observing their ability to perform the tasks. For persons with memory problems, the use of surrogate reporters (proxy reports) such as family members or caregivers may be necessary, keeping in mind that they may either overestimate or underestimate their actual abilities.

6. When using the various instruments to assess an older person's activities of daily living (ADLs), the nurse needs to remember that a disadvantage of these instruments includes: A. The reliability of the tools. B. Self or proxy report of functional activities. C. Lack of confidentiality during the assessment. D. Insufficient detail about the deficiencies identified.

ANS: B A disadvantage of many of the ADL and IADL instruments is the self or proxy report of functional activities. The other responses are not correct.

13. During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards? A. "These low toilet seats are safe because they are nearer to the ground in case of falls." B. "Do you have a relative or friend who can help to install grab bars in your shower?" C. "These small rugs are ideal for preventing you from slipping on the hard floor." D. "It would be safer to keep the lighting low in this room to avoid glare in your eyes."

ANS: B Environmental hazards within the home can be a potential constraint on the older person's day-to-day functioning. Common environmental hazards including inadequate lighting, loose throw rugs, curled carpet edges, obstructed hallways, cords in walkways, lack of grab bars in tub and shower, and low and loose toilet seats are hazards that could lead to an increased risk of falls and fractures. Environmental modifications can promote mobility and reduce the likelihood of the older adult falling.

12. An elderly patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? A. The Lawton IADL instrument B. Hospital Admission Risk Profile (HARP) C. The Mini-Cog D. The NEECHAM Confusion Scale

ANS: B Hospital-acquired functional decline may occur within two days of a hospital admission. The HARP helps to identify older adults who are at greatest risk for loss of ADLs or mobility at this critical time. The Lawton IADL measures instrumental activities of daily living, which may be difficult to observe in the hospital setting. The Mini-Cog is an assessment of mental status. The NEECHAM Confusion Scale is used to assess for delirium.

14. When beginning to assess a person's spirituality, which question by the nurse would be most appropriate? A. "Do you believe in God?" B. "How does your spirituality relate to your health care decisions?" C. "What religious faith do you follow?" D. "Do you believe in the power of prayer?"

ANS: B Open-ended questions provide a foundation for future dialog. The other responses are easily answered by one-word replies, and they are closed questions.

4. The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? A. The nurse uses direct observation to implement this tool. B. It is designed as a self-report measure of performance rather than ability. C. It is not useful in the acute hospital setting. D. It is best used for those residing in an institutional setting

ANS: B The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. Direct testing is often not feasible, such as demonstrating the ability to prepare food while a hospital inpatient. Attention to the final score is less important than identifying a person's strengths and areas where assistance is needed. The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings. It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident.

16. The nurse is assessing the abilities of an older adult. Which of these following activities are considered instrumental activities of daily living? Select all that apply. A. Feeding oneself B. Preparing a meal C. Balancing a checkbook D. Walking E. Toileting F. Grocery shopping

ANS: B, C, F Typically, instrumental activities of daily living tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation. The others listed are activities of daily living related to self-care.

11. During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status? A. Geriatric Depression Scale, Short Form B. The Physical Performance Test C. Mini-Cog D. The Get Up and Go Test

ANS: C For nurses in various settings, cognitive assessments provide continuing comparisons to the individual's baseline to detect any acute changes in mental status. The Mini-Cog is a mental status test that tests immediate and delayed recall and visuospatial ability. The Geriatric Depression Scale, Short Form assess for depression and changes in the level of depression, not mental status. The Physical Performance Test assesses activities such as eating, dressing, transferring, and stair climbing, but not mental status. The Get Up and Go Test assesses functional mobility, not mental status.

15. The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain.Which statement about pain and the older adult is true? A. Pain is inevitable with aging. B. Older adults with cognitive impairments feel less pain. C. Alleviating pain should be a priority over other aspects of the assessment. D. The assessment should take priority so that care decisions can be made.

ANS: C If the older adult is experiencing pain or discomfort, then the depth of knowledge gathered through the assessments will suffer. Alleviating pain should be a priority over other aspects of the assessment. It is paramount to remember that older adults with cognitive impairment do not feel less pain.

3. The nurse needs to assess a patient's ability to perform activities of daily living and should choose which tool for this assessment? A. Direct Assessment of Functional Abilities (DAFA) B. Lawton IADL C. Barthel Index D. Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL (OARS-IADL)

ANS: C The Barthel Index is used to assess activities of daily living. The other options are used to measure instrumental activities of daily living

7. The nurse is administering a test that is timed over 15 minutes and assesses a patient's upper body fine motor and coarse motor activities, balance, mobility, coordination, and endurance. During this test, activities such as dressing and stair climbing are timed. Which test is described by these activities? A. The Get Up and Go Test B. The Performance Activities of Daily Living C. The Physical Performance Test D. Tinetti Gait and Balance Evaluation

ANS: C The Physical Performance Test is appropriate for use with community-dwelling older adults. The test requires approximately 15 minutes to complete and assesses upper body fine motor and coarse motor activities, balance, mobility, coordination, and endurance. Activities such as eating, dressing and transferring, and stair climbing are simulated and timed.

1. The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability? Functional ability: A. Is the measure of the expected changes of aging that one is experiencing. B. Refers to the individual's motivation to live independently. C. Refers to the level of cognition present in an older person. D. Refers to one's ability to perform activities necessary to live in modern society.

ANS: D Functional ability refers to one's ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks such as bathing and toileting.

9. The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support? A. The local senior center B. Her Medicare check C. Meals on Wheels meal delivery service D. Her neighbor, who visits with her daily

ANS: D Informal support includes family and close long-time friends and is usually provided free of charge. Another example of informal support is a neighbor who has daily contact with the client and shares food and company. Formal supports include programs such as social welfare and other social service and health care delivery agencies such as home health care. Semi formal supports such as church societies, neighborhood groups, and senior centers also form an important role in social support.