Functional Ability PrepU - Fundamentals

The nurse should identify the need for further teaching when the client with diabetes who is taking daily insulin and follows a strict diet makes which statement?

"I cannot possibly ever be considered as healthy."

A nurse was injured when a client with Alzheimer disease struck the nurse on the side of the head during a transfer. The nurse has completed an incident report. Which statement about an incident report is most accurate?

The report provides a detailed and objective account of the circumstances before, during, and after the event.

The nurse is creating a plan of care for the older adult who has multiple medications and a difficult time reading medication labels due to poor eyesight. What is the most appropriate nursing diagnosis to include in this client's plan of care?

Risk for Poisoning related to poor eyesight and the inability to read medication labels

A nurse is a member of an interdisciplinary team providing home health care to a client who was discharged home after experiencing a stroke. The client has been receiving services to assist with swallowing. The nurse would collaborate with which member of the team to discuss the client's progress?

Speech therapist

An 82-year-old client is being discharged from the hospital following a bowel resection. The client lives alone and the client's family is out of town. Which factor will have the greatest effect on the client's home care management?

Support system

The nurse is planning discharge of the client who had surgery for a left hip replacement. The client is being discharged from the hospital to the home and requires home medical services. Which item would be provided by home medical services?

High-rise toilet seat

A client living alone has degenerative joint disease, hypertension, and neuropathy. It is difficult for the client to bathe, and the client's blood pressure is unstable. Which type of care would this client benefit from most?

Home care

Which is the primary criterion for admission to a long-term care facility?

Inability to provide self-care

A nurse is teaching an older adult client to use an incentive spirometer following hip replacement surgery when the client asks why using this machine is necessary. How will the nurse respond?

The exercise helps prevent pneumonia.

The nurse is planning instruction on wound care to an adult client. What variables would cause the nurse to alter the education plan? Select all that apply.

-The client is blind. -The client denies the need for education.

A nurse is working with an older adult client, educating the client on how to ambulate with the aid of a walker. The nurse notes that the client appears to lack the motivation to learn how to use the device. The client states, "I'm just too old to learn." What would be most appropriate for the nurse to do to motivate this client?

Describe how the walker can improve the client's quality of life.

The client is in a rehabilitation unit after a traumatic brain injury. In order to facilitate the client's recovery, what would be the nurse's most appropriate intervention?

Encourage the client to provide as much self-care as possible.

A new graduate nurse has accepted a staff position on a geriatric unit. The preceptor determines that the new nurse understands gerontologic nursing when which statement is made?

"Normal changes that occur with aging result from complex interactions."

A female client has recently had surgery for cervical cancer and asks the nurse about other ways she can have sex with her husband. Which of the following statements by the nurse is most accurate?

"Stimulation of the genitals by the mouth and tongue may be used to reach orgasm."

A nurse is teaching an older adult client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following?

"Sundowning is a common problem dementia."

A new client is admitted to the hospital and requires a comprehensive admission assessment. What should the nurse include in this assessment? Select all that apply.

-Functional ability evaluation -Collection of subjective data -Complete set of vital signs

The health care provider tells the nurse that the older adult client has presbycusis. Which of the following interventions will the nurse place in the client's care plan?

Decrease background noises, as much as possible, before speaking.

A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?

Nebulizer

A nurse is caring for an adolescent who has just lost a leg in a motor vehicle accident. Which human need would the nurse most likely need to address?

Self-esteem needs

The nurse is counseling an older adult client. Because of the client's age, the nurse recognizes that she is at risk for macular degeneration. Which of the following is a priority nursing intervention?

Teach the client signals of serious eye problems, such as visual disturbances.

What is the purpose of establishing a nursing diagnosis?

To describe a functional health problem

The nurse teaches proper body mechanics for a group of unlicensed assistive personnel (UAP). Which statement by a class participant indicates the need for additional education?

When I lift and carry a heavy box of supplies I will keep it at arm's length from my body.

Which type of mobility aid would be most appropriate for a client who has poor balance?

a cane with four prongs on the end (quad cane)

A client has a diagnosis of Bathing/Hygiene Self-care Deficit due to recent surgery and decreased strength. An appropriate goal to include in the client's plan of care would be:

client will participate in self-care measures by the end of the week.

A client who is blind is said to be experiencing:

sensory deficit.

The nurse is assisting an older adult client with dementia in getting dressed after morning care. Which statement would be most beneficial to the client?

"Put your arm in this sleeve."

A nurse is planning care for an adult client with severe hearing impairment who uses sign language and lip reading for communication and who has a new diagnosis of cancer. Which nursing action is most appropriate when establishing the plan of care for this client?

Arrange for a sign language interpreter when discussing treatment.

The nurse is caring for an adult client that had a cerebrovascular accident (CVA) 1 month ago. How would the nurse assist the client in relearning self-care?

Assist the client in dressing oneself after offering alternative techniques

An older adult client is becoming progressively confused due to Alzheimer's disease. The family can no longer manage the client at home due to wandering. Which of the following living arrangements could the nurse recommend?

Extended-care facility

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

stress

A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?

stress

The nurse is working to increase functional ability of a client who is bedbound. Which assistive technique should the nurse prioritize in the plan of care?

trapeze bar