The nurse is assessing the older adult client who has been admitted to the hospital following a fall. The nurse is using the Fulmer SPICES framework to assess the client for predicting and preventing problems that the client may experience
Rank the following assessment questions by the nurse in order of occurrence based on this framework. Standard Text: Click and drag the options below to move them up or down. 1. "Do you have any concerns about your memory?"
2. "It looks like you've lost some weight since your healthcare provider last saw you. How are your teeth?"
3. "Can you tell me about how well you are sleeping?"
4. "Have you had any problems holding your urine?"
5. "I noticed that you have a large bruise on your knee. Did you fall recently?"
3,2,4,5,1
Rationale 1: The first thing to assess is how well the client is sleeping. The nurse needs to determine if the client may be experiencing any sleep disorders.
Rationale 2: The second thing is for the nurse to determine if the client is having any difficulty eating or feeding him or herself.
Rationale 3: The third thing is for the nurse to determine if the client is experiencing any difficulties with incontinence.
Rationale 4: The nurse must then assess for any clinical manifestations of confusion. Following that, the nurse can assess for any evidence that the client has fallen.
Rationale 5: The last thing is for the nurse to assess for any evidence of skin breakdown.
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