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The nurse is preparing to do a functional assessment. Which statement best describes the
purpose of a functional assessment?
A. It assesses how the individual is coping with life at home.
B. It determines how children are meeting developmental milestones.
C. It can identify any problems with memory the individual may be experiencing.
D. It helps to determine how a person is managing day-to-day activities.
D. It helps to determine how a person is managing day-to-day activities.
Page: 67. The functional assessment measures how a person manages day-to-day activities.
The other answers do not reflect the purpose of a functional assessment.
The nurse is performing a functional assessment on an 82-year-old patient who recently had a
stroke. Which of these questions would be most important to ask?
A. "Do you wear glasses?"
B. "Are you able to dress yourself?"
C. "Do you have any thyroid problems?"
D. "How many times a day do you have a bowel movement?"
B. "Are you able to dress yourself?"
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,Page: 67. Functional assessment measures how a person manages day-to-day activities. For
the older person, the meaning of health becomes those activities that they can or cannot do.
The other responses do not relate to functional assessment.
The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the
assessment, the nurse expects that this patient:
A) will have no decrease in any of his abilities, including response time.
B) will have difficulty on tests of remote memory because this typically decreases with age.
C) may take a little longer to respond, but his general knowledge and abilities should not have
declined.
D) will have had a decrease in his response time because of language loss and a decrease in
general knowledge.
C) may take a little longer to respond, but his general knowledge and abilities should not have
declined.
Page: 72. The aging process leaves the parameters of mental status mostly intact. There is no
decrease in general knowledge and little or no loss in vocabulary. Response time is slower
than in youth. It takes a bit longer for the brain to process information and to react to it.
Recent memory, which requires some processing is somewhat decreased with aging, but
remote memory is not affected.
The nurse is preparing to do a mental status examination. Which statement is true regarding the
mental status examination?
A) A patient's family is the best resource for information about the patient's coping skills.
B) It is usually sufficient to gather mental status information during the health history interview.
C) It takes an enormous amount of extra time to integrate the mental status examination into
the health history interview.
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,D) It is usually necessary to perform a complete mental status examination to get a good idea of
the patient's level of functioning.
B) It is usually sufficient to gather mental status information during the health history interview.
Page: 73. The full mental status examination is a systematic check of emotional and cognitive
functioning. The steps described here, though, rarely need to be taken in their entirety.
Usually, one can assess mental status through the context of the health history interview.
During a mental status examination, the nurse wants to assess a patient's affect. The nurse
should ask the patient which question?
A) "How do you feel today?"
B) "Would you please repeat the following words?"
C) "Have these medications had any effect on your pain?"
D) "Has this pain affected your ability to get dressed by yourself?"
A) "How do you feel today?"
Page: 74. Judge mood and affect by body language and facial expression and by asking
directly, "How do you feel today?" or "How do you usually feel?" The mood should be
appropriate to the person's place and condition and should change appropriately with topics.
During a mental status assessment, which question by the nurse would best assess a person's
judgment?
A) "Do you feel that you are being watched, followed, or controlled?"
B) "Tell me about what you plan to do once you are discharged from the hospital."
C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?"
D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"
B) "Tell me about what you plan to do once you are discharged from the hospital."
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, Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the
alternatives in a situation and reach an appropriate course of action. Rather than testing the
person's response to a hypothetical situation (as illustrated in the option with the envelope),
the nurse should be more interested in the person's judgment about daily or long-term goals,
the likelihood of acting in response to delusions or hallucinations and the capacity for violent
or suicidal behavior.
The Nurse is interviewing their patient. The nurse states "Can you tell me exactly what you feel
when you are having difficulty catching your breath?" Which of the following communication
techniques is the nurse utilizing?
A) Attending to cues
B) Paraphrasing
C) Focusing
D) Summarazing
C) Focusing
The nurse is obtaining a family health history when the client reports that a grandparent has
type 1 diabetes. Where can the nurse document this information?
A) Present health/ illness
B) Family Genogram
C) Past Medical History
D) Health Belief Model
B) Family Genogram
The Nurse is interviewing a patient with acute pain. Which of the following actions by the nurse
should be preformed first?
A) Attempt to reduce the pain and complete the interview later
B) Interview the family to get the information needed
C) Document why the interview could not be completed at this time
D) Proceed very quickly with the interview
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