A 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.
Ans: D
The presence of cognitive deficits presents a challenge to the assessment of a client's ADLs. However, there are assessment instruments that are designed for this explicit purpose and these should be utilized. The nurse should not forgo functional assessment. Observation and input from family should be included in assessment, but these do not replace a formal, functional assessment.
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