A nurse working in an acute care for elders unit observes that a client on the unit frequently stumbles when ambulating with a walker. Which action by the nurse is best?
A) Provide a wheelchair for the client to use for the duration of the hospital stay.
B) Ask the client to remain in bed as much as possible and teach the client about falls risks.
C) Place a chair in the hallway so the client can take a rest break when feeling unsteady.
D) Ensure that the woman's mobility is assessed and the appropriate assistive device is provided.
Question 2A nurse assesses a 91-year-old client in long-term care healing from bilateral broken legs caused in a fall. Today, the client developed new onset confusion and combativeness.
Which of the factors must the nurse investigate as a source of this mental status state? (Select all that apply.)
A) Social separation
B) Hyponatremia
C) Medication interactions
D) Positional pain
E) Urinary tract infection
Question 3Assessment of an older adult's ADLs addresses parameters such as mobility, dressing, and elimination. In addition to these, which of the following categories should the functional assessment also include?
A) Pain
B) Mental status
C) Previous medical history
D) Integumentary assessment
Question 4A nurse discusses driving with an older adult who continues to drive, but is probably unsafe on the road. Which statement made by the nurse is most appropriate?
A) I am calling your child to take your keys.
B) I am concerned about your safety, as well as the safety of others.
C) We just don't want you to crash when you drive across the state.
D) You shouldn't drive anymore.
Question 5A 79-year-old client has been admitted to a long-term care facility because of the progression of Alzheimer disease from mild to the moderate stage. How should the nurse proceed with functional assessment?
A) Document the fact that it is not possible to accurately gauge the woman's ADLs.
B) Obtain assessment data from the woman's family members and friends.
C) Perform assessment passively by observing and recording the woman's behavior and actions over the next several days.
D) Use an assessment tool that is specifically designed for use with cognitively impaired clients.
Question 6As part of a functional assessment, a nurse is assessing an older adult's ADLs and instrumental activities of daily living (IADLs). What piece of assessment data would most likely be considered an IADL rather than an ADL?
A) The older adult is able to ambulate to and from the bathroom at home.
B) The older adult can feed herself independently.
C) The older adult can dress in the morning without assistance.
D) The older adult is able to clean and maintain her own apartment.
Question 7A nurse completes the admission assessment of an 84-year-old client to the long-term care facility. Which assessment finding would direct the nurse to document a deficit in the client's ADLs?
A) The client experiences chronic pain as a result of rheumatoid arthritis.
B) The client is able to ambulate with a wheeled walker for 60 ft but then requires a rest break.
C) The client is able to wash self but requires assistance entering and leaving the bathtub.
D) The client is unable to explain the rationale for each of the prescribed medications.
Question 8A nurse in a Medicare- and Medicaid-funded nursing home performs assessments and develops care plans. Which of these statements is true of the functional assessments the nurse is likely to perform?
A) The nurse will address core ADLs but not more complex IADLs.
B) The nurse will identify changes in the older adult's function over time.
C) The nurse will utilize various functional assessment models.
D) The main goal of functional assessments will be to ensure older adult safety.
Question 9An 82-year-old client is getting advice from a family member on how to drive safely. What piece of advice should the older adult follow?
A) Avoid modifying your vehicle with devices that were not supplied by the manufacturer.
B) Realize that normal, age-related changes should not affect your ability to drive safely.
C) You can consider timing your medications to avoid their interfering with safe driving.
D) You should transition from driving to using public transportation as soon as possible.
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