Functional Ability

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 most appropriate?

"Do you use a cane, walker, or wheelchair to ambulate?"

Uncontrollable risk factors for CVA

-Age -Sex -Race -Genetics

Difference between Basic Activities of Daily Living and Instrumental Activities of Daily Living

-BADLs are self-care activities (i.e. bathing, eating, dressing, toileting) -IADLs are the activities needed for independent living

Management of Parkinson's

-Exercise and ambulation - non-traditional, but aggressive PT is becoming popular -OT collaboration -Injury prevention -Assess sleeping pattern -Nutrition - as disease progresses, PEG tube/enteral nutrition may be required -Communication -ST collaboration -Psychosocial support

Controllable risk factors for CVA

-HTN -Atrial fibrillation -Increased lipids -Smoking -Obesity

Possible nursing diagnoses for Parkinson's disease

-Impaired physical mobility and risk for activity intolerance -Self-care deficits -Risk/actual Imbalanced nutrition -Constipation -Impaired verbal communication -Ineffective coping/compromised family coping -Risk for injury

Parkinson's disease - planning

-Improved functional ability -Maintaining independence in ADLs -Achieving adequate bowel elimination -Attaining and maintaining acceptable nutritional status -Achieving effective communication -Developing positive individual and family coping skills

Parkinson's meds

-Levadopa - tremors -Modenifil - anxiety -Dopamine agonists - stimulate dopamine in brain

Alzheimer's disease

-Most common cause of dementia -Chronic, progressive, degenerative brain disorder -Characterized by loss of memory, judgment, and visual-spatial perception with changes in personality

Long term results of CVA

-Motor function changes -Flaccidity to spastic limbs -Aphasia (expressive, receptive) -Hemaniopia -Impaired judgment -Unilateral neglect

Difference between primary functional ability deficit and secondary functional ability deficit

-Primary is when a particular function never develops -Secondary represents a loss of functional ability

Parkinson's Disease

-Slowly progressing neurologic movement disorder that eventually leads to disability -Associated with decreased levels of dopamine due to destruction of cells in the substantia nigra in the basal ganglia, which affects the neurotransmission of impulses

Cerebrovascular accident (CVA)

-Stroke -Prolonged interruption of blood supply through artery -Brain cells begin to die in 3-7 mins w/o O2 (IRREVERSIBLE)

Parkinson's disease manifestations

-Tremor -Rigidity -Bradykinesia -Postural instability -Depression and other psychiatric changes -Dementia -Autonomic symptoms -Sleep disturbances

2 basic categories of functional ability are basic activities of daily living (BADL) and instrumental activities of daily living (IADL). BADLs include _____ (select all that apply): A. Eating B. Bathing C. Cooking D. Toileting E. Managing money F. Mouth care

A, B, C, D, F

Which type of mobility aids would be most appropriate for a client who has poor balance? A. A cane with four prongs on the end (quad cane) B. A single-ended cane with a half-circle handle C. A single-ended cane with a straight handle D. Axillary crutches

A. A cane with four prongs on the end (quad cane)

While assessing a full-term neonate, which symptom would cause the nurse to suspect a neurologic impairment? A. a weak sucking reflex B. a positive rooting reflex C. a positive Babinski's reflex D. startle reflex in response to a loud noise

A. A weak sucking reflex

A nurse tests a newborn's nervous functioning by stroking the sole of the baby's foot in an inverted "J" curve from the heel upward. The baby responds by fanning his toes. Which reflex has just been demonstrated? A. Babinski reflex B. rooting reflex C. extrusion reflex D. Moro reflex

A. Babinski reflex

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 which of the following? A. Client will participate in self-care measures by the end of the week. B. Client will recognize the need for self-care. C. Client will verbalize the need to use to use the bedpan by the end of shift. D. Client will consent to no hygiene measures.

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

The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patient's tumor, the nurse should implement measures to prevent what complication? A. Falls B. Audio hallucinations C. Respiratory depression D. Labile BP

A. Falls

Which type of fracture occurs when a bone fragment is driven into another bone fragment? A. Impacted B. Oblique C. Spiral D. Transverse

A. Impacted

The nurse educator has just completed a lecture regarding the elderly and hazards in the home. The nurse educator recognizes that teaching was effective when the students state that common dangers in the home setting of an elderly adult include which of the following? A. Polypharmacy and use of multiple extension cords B. Household cleaners stored under the sink and hanging cords on window blinds C. Peeling paint and easy access to the backyard pool D. Risky behaviors and cyber-bullying

A. Polypharmacy and multiple extension cords

A 65-year-old female patient has been admitted to the med-surg unit. The nurse is assessing the patient's risk for functional impairment so that prevention measures can be implemented if necessary. Select all the functional impairment risk factors that apply from this patient's history and physical. A. Being a woman B. Taking more than 6 meds C. Having hypertension F. Having cataracts G. Non-smoker H. Urge incontinence

B, C, F, H

You are the nurse planning an educational event on the topic of the normal signs of aging to a group of senior citizens. What would you include in your teaching plan? A. An enhanced sense of smell B. A decrease in muscle mass C. The disappearance of sexual desire for both men and women D. An increase in sebaceous and sweat glands for both men and women

B. A decrease in muscle mass

Which act mandates that people with disabilities have access to job opportunities and to the community? A. Rehabilitation Act of 1973 B. Americans with Disabilities Act of 1990 C. Title II D. Title XVI

B. Americans with Disabilities Act of 1990

A client is admitted with fatigue, anorexia, weight loss, and inability to sleep, which started 1 month after the death of their spouse. Which nursing diagnosis is most appropriate for this client? A. activity intolerance B. complicated grieving C. ineffective role performance D. low self-esteem

B. Complicated grieving

Down syndrome is categorized as which of the following? A. An acquired disability B. A developmental disability C. An age-related disability D. An acute nontraumatic disorder

B. Developmental disability

The nurse assesses a client who has Alzheimer's disease. Her hair is dirty; her clothing is soiled and has an odor of urine. What should the nurse do? A. Ask the client when was the last time she bathed and changed her clothes. B. Help the client with her bath, allowing her to do as much for herself as she is able. C. Ask the daughter to bathe her mother D. Instruct the client to bathe and put on clean clothing.

B. Help the client with her bath, allowing her to do as much for herself as she is able.

A 65-year-old woman suffers from a condition where bone destruction exceeds bone formation and in which the resultant thin, porous bones fracture easily. This client is most likely diagnosed with which disorder? A. Achondroplasia B. Osteoporosis C. Vitamin D deficiency D. Osteogenesis imperfecta

B. Osteoporosis

The nurse is assessing the home environment of an elderly client who is using crutches during the postoperative recovery phase after hip pinning. Which poses the greatest hazard to the client as a risk for falling at home? A. a 4-year-old cocker spaniel B. scatter rugs C. snack tables D. rocking chairs

B. Scatter rugs

A nurse is preparing to medicate an elderly patient with an opioid analgesic. Which of the following does the nurse consider in the use of this medication? A. Pain is a normal consequence of aging. B. Older adults are frequently prescribed higher doses of opioid analgesics than younger adults. C. Delirium, sleep disturbances, cognitive changes, and diminished functional abilities may result when pain is not managed adequately. D. Pain is often experienced by older adults and is usually adequately treated.

C. Delirium, sleep disturbances, cognitive changes, and diminished functional abilities may result when pain is not managed adequately.

The nurse is working with a rehabilitation patient who has a deficit in mobility following a skiing accident. The nurse knows that preparation for ambulation is extremely important. What nursing action will best provide the foundation of preparation for ambulation? A. Stimulating the patient's desire to ambulate B. Assessing the patient's understanding of ambulation C. Helping the patient perform frequent exercise D. Setting realistic expectations

C. Helping the patient perform frequent exercise

A client with Alzheimer's disease has memory loss, wandering, and disorientation. What nursing intervention will appear in this client's care plan? A. Provide the client with detailed instructions. B. Keep the client sedated whenever possible. C. Remove potential hazards from the client's environment. D. Reorient the client to their environment every hour.

C. Remove potential hazards from the client's environment

All of the following are antecedents of functional ability except: A. Developmental milestones B. Acquisition of learning skills C. Learning D. Capacity to perform

Capacity to perform

The nurse is assessing the patient's functional performance. What assessment parameters will be most important in this assessment?

Continence assessment, gait performance, feeding assessment, dressing assessment, transfer assessment

Parents of a newborn with Down syndrome are tearful when they tell the nurse that the diagnosis was a surprise to them. Which statement by the parents indicates that they have some understanding of Down syndrome? A. "Children with Down syndrome are often fearful of strangers and have difficulty making friends." B. "At some point during their lifespan, children with Down syndrome will need to be institutionalized." C. "Children with Down syndrome often become violent when they experience hormonal changes during puberty." D. "There's a broad spectrum of mental capabilities and physical characteristics of children with Down syndrome."

D. "There's a broad spectrum of mental capabilities and physical characteristics of children with Down syndrome."

The 55 year-old client who is newly diagnosed with osteoarthritis of the hips asks the nurse why it hurts when walking. What is the nurse's best response? A. "If you recently fell, you might have a fractured hip." B. "Osteoarthritis is painful and very common as you age." C. "Because you lose muscle tone with age, it hurts to walk." D. "You have lost the padding in your joints and the friction causes pain."

D. "You have lost the padding in your joints and the friction causes pain."

A 93-year-old male patient with failure to thrive has begun exhibiting urinary incontinence. When choosing appropriate interventions, you know that various age-related factors can alter urinary elimination patterns in elderly patients. What is an example of these factors? A. Decreased residual volume B. Urethral stenosis C. Increased bladder capacity D. Decreased muscle tone

D. Decreased muscle tone

The nurse is assessing a patient's functional ability. Which activities most closely match the definition of positive functional ability?

Healthy individual, cooks own meals, well groomed, reads well

The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. What interventions would be most critical to developing a plan of care for this patient?

Maintaining a safe environment, breathing, maintaining temperature

Problems that represent a loss of functional ability are called _____

Secondary problems

Two basic types of assessment tools are _____

Self-report and performance based

Functional ability definition

The physical, psychological, cognitive, and social ability to carry on normal activities of life

Types of CVA

ischemic (thrombolytic) and hemorrhagic