The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the client's:

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Question 1 of 5

The nurse performs a functional assessment of a client upon admission to a home health service. The purpose of this assessment is to determine the client's:

Correct Answer: B

Rationale: The correct answer is B: Ability to perform activities of daily living. A functional assessment in home health services focuses on evaluating the client's ability to independently perform daily tasks such as bathing, dressing, and preparing meals. This assessment helps determine the client's level of independence and need for assistance. Choices A, C, and D are incorrect because they do not directly assess the client's ability to perform activities of daily living, which is the primary purpose of a functional assessment in this context.

Question 2 of 5

A patient was abducted and raped at gunpoint by an unknown assailant. Which nursing interventions are appropriate while caring for the patient in the emergency department? Select all that apply.

Correct Answer: A

Rationale: The correct answer is A: Allow the patient to talk at a comfortable pace. This intervention is appropriate because it promotes the patient's autonomy and empowerment in sharing their experience, which can be therapeutic. It also helps establish trust and rapport, facilitating effective communication and assessment. Incorrect choices: B: Placing the patient in a private room with a caregiver can be important for privacy and support but may not be the immediate priority. C: Posing questions in nonjudgmental, empathetic ways is crucial but may not be as important as allowing the patient to talk at their own pace initially. D: None of the above is incorrect as allowing the patient to talk is a crucial step in providing appropriate care for a patient who has experienced trauma.

Question 3 of 5

Asking the husband to leave is likely to increase the client's anxiety and alter test results. Testing in the more familiar, comfortable surroundings of the home will yield more reliable results.

Correct Answer: C

Rationale: The correct answer is C because both statements A and B provide valid reasons supported by psychological principles. Statement A is correct as the presence of a loved one can indeed provide comfort and support, reducing anxiety and potentially improving test outcomes. Statement B is also accurate as testing in familiar surroundings can help the client feel safe and secure, leading to more reliable results. Therefore, combining these two factors - the presence of a loved one and testing in a comfortable environment - would likely yield the most reliable results by addressing both emotional and environmental factors impacting the client's anxiety levels during the test.

Question 4 of 5

What environmental conditions should the nurse arrange for a patient with delirium and altered perceptions of their environment?

Correct Answer: A

Rationale: The correct answer is A because a quiet, well-lit room without glare or shadows helps reduce environmental stimuli that can exacerbate delirium and altered perceptions. This environment promotes calmness and clarity for the patient. Choice B is incorrect as it may increase distractions and stimuli. Choice C may lead to inadequate lighting that can worsen confusion. Choice D is incorrect as environmental modifications are crucial for managing delirium.

Question 5 of 5

A patient with Alzheimer's disease has been determined to have a dressing/grooming self-care deficit. Which intervention(s) would be appropriate for this nursing diagnosis? Select all that apply.

Correct Answer: A

Rationale: Rationale: Option A is correct because replacing personal clothing with matching gym clothes simplifies dressing, reducing confusion for a patient with Alzheimer's. This intervention promotes independence and minimizes frustration. Labeling clothing (Option B) may help in identifying items but does not address the deficit. Clothing with elastic waistbands and closures (Option C) may be helpful but does not directly address the deficit. "None of the above" (Option D) is incorrect as Option A is an appropriate intervention.

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