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

a. Continence assessment, gait assessment, feeding assessment, dressing assessment, transfer assessment
b. Height, weight, body mass index (BMI), vital signs assessment
c. Sleep assessment, energy assessment, memory assessment, concentration assessment
d. Health and well-being, amount of community volunteer time, working outside the home, and ability to care for family and house


ANS: A
Functional impairment, disability, or handicap refers to varying degrees of an individual's inability to perform the tasks required to complete normal life activities without assistance. Height, weight, BMI, and vital signs are part of a physical assessment. Sleep, energy, memory, and concentration are part of a depression screening. Healthy, volunteering, working, and caring for family and house are functional abilities, not performance.

Nursing

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A grieving widow tells a psychiatric–mental health nurse, "I feel so tired and alone." The nurse who incorporates an understanding of symbolic interactionism in practice would not suggest which of the following to the client?

1. "You had a terrible loss. Feeling tired and alone must be very difficult for you." 2. "I would like to hear more about how you are feeling now." 3. "Try to get plenty of rest. Most people who suffer losses like yours need more sleep than usual to cope effectively." 4. "You seem sad. Can I sit with you for a while?"

Nursing

When performing a client's physical assessment, the nurse notes that the client has conductive hearing loss. Which finding does the nurse expect to see in the client's medical history?

a. History of diabetes with peripheral neu-ropathy b. Frequent episodes of otitis media during childhood c. History of frequent impactions of cerumen in the ear canals d. History of osteomyelitis treated with IV gentamicin (Garamycin)

Nursing

A mother is breastfeeding her newborn infant but is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint

The best nursing response would be to: a. tell the client to wear a bra at all times to provide more support to breast tissue. b. have the client put the infant to her breast more frequently. c. place ice packs on breast tissue after infant feeding. d. explain that this is a normal finding and will resolve as her breast tissue becomes more used to nursing.

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A patient recently was discharged from the hospital and prescribed ciprofloxacin (Cipro) phones the prescriber's office complaining of pain above the heel while walking or stretching. The nurse should instruct the patient to

a. try isometric exercises prior to walking or stretching. b. avoid the treadmill and apply ice to area. c. continue the medication and watch for signs of redness or swelling. d. discontinue the medication and avoid weight bearing on the ankle.

Nursing