A nurse is caring for a client scheduled for a functional assessment who asks, “What is the purpose of this assessment?” How should the nurse most appropriately respond to the client?
“It is a test that determines which activities you feel most comfortable performing.”
“It is a tool that is used to determine your maximum level of self-sufficiency.”
“It is a tool that is used to assess what services you will need a home health aide to perform for you.”
“It is a tool used by insurance companies to determine qualifications for medical reimbursement.”
The Correct Answer is B
Choice A reason:
“It is a test that determines which activities you feel most comfortable performing” is not entirely accurate. While comfort with activities may be assessed, the primary goal of a functional assessment is to evaluate the client’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Choice B reason:
“It is a tool that is used to determine your maximum level of self-sufficiency.” This response accurately reflects the purpose of a functional assessment. The assessment evaluates the client’s ability to perform ADLs and IADLs independently, which helps determine the level of assistance they may need.
Choice C reason:
“It is a tool that is used to assess what services you will need a home health aide to perform for you” is partially correct but not comprehensive. While the assessment can help identify the need for home health aide services, its primary purpose is to evaluate overall self-sufficiency and functional status.
Choice D reason:
“It is a tool used by insurance companies to determine qualifications for medical reimbursement” is not the primary purpose of a functional assessment. Although the results may be used for insurance purposes, the main goal is to assess the client’s functional abilities and needs.
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View Related questions
Correct Answer is C
Explanation
Choice A reason:
The Romberg test is not used to measure respiratory rate and depth. Respiratory assessments involve observing breathing patterns, rate, and depth, which are unrelated to the Romberg test.
Choice B reason:
While the Romberg test can provide some information about coordination, its primary purpose is not to evaluate fine motor skills. Fine motor skills are typically assessed through tasks that involve precise hand and finger movements.
Choice C reason:
The Romberg test is used to test for proprioception and vestibular function. It assesses the client’s ability to maintain balance with their eyes closed, which helps identify issues with proprioception (the sense of body position) and vestibular function (the inner ear’s role in balance).
Choice D reason:
The Romberg test does not assess cranial nerve function related to facial expression. Cranial nerve assessments involve specific tests for each nerve, such as asking the client to smile or raise their eyebrows to evaluate facial nerve function.
Correct Answer is B
Explanation
Choice A reason:
A gradual onset of headache is more characteristic of other types of headaches or conditions, such as tension headaches or migraines. Hemorrhagic strokes, particularly those caused by a ruptured cerebral aneurysm, typically present with a sudden and severe headache, often described as the “worst headache of my life.” This sudden onset is due to the rapid accumulation of blood in the brain, which increases intracranial pressure and causes immediate symptoms.
Choice B reason:
Changes in consciousness are a common manifestation of a hemorrhagic stroke. The sudden bleeding into the brain can disrupt normal brain function, leading to symptoms such as confusion, lethargy, or loss of consciousness. These changes occur rapidly and are a key indicator of a serious neurological event. The nurse should be vigilant for any alterations in the client’s level of consciousness, as this can signify worsening of the condition and the need for immediate medical intervention.
Choice C reason:
A gradual onset of several hours is not typical for hemorrhagic strokes. These strokes usually present with sudden and severe symptoms due to the abrupt rupture of a blood vessel in the brain. The rapid increase in intracranial pressure from the bleeding causes immediate and severe symptoms, rather than a slow progression over hours.
Choice D reason:
A history of neurologic deficits lasting less than 1 hour is more indicative of a transient ischemic attack (TIA), also known as a mini-stroke. TIAs are temporary and resolve within a short period without causing permanent damage. In contrast, a hemorrhagic stroke caused by a ruptured cerebral aneurysm results in immediate and severe symptoms that do not resolve quickly and require urgent medical attention.