Chapter 31: Functional Assessment of the Older Adult
Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition
MULTIPLE CHOICE
1. The nurse is assessing an older adult’s functional ability. The nurse will need to determine the patien
a. Experience of the expected changes of aging.
b. Motivation to live independently
c. Level of cognition
d. Ability to perform activities necessary to live in modern society
ANS: D
Functional ability refers to one’s ability to perform activities necessary to live in modern society and
the telephone, or performing personal tasks, such as bathing and toileting.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
2. The nurse is preparing to perform a functional assessment with an older patient and knows that a goo
a. Observe the patient’s ability to perform the tasks
b. Ask the patient’s wife how he does when performing tasks
c. Review the medical record for information on the patient’s abilities
d. Ask the patient’s physician for information on the patient’s abilities
ANS: A
Two approaches are used to perform a functional assessment: (1) asking individuals about their abilit
(self-reports), or (2) actually observing their ability to perform the tasks. For persons with memory p
reporters (proxy reports), such as family members or caregivers, may be necessary, keeping in mind
overestimate or underestimate the person’s actual abilities.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The nurse needs to assess a patient’s ability to perform activities of daily living (ADLs) and should c
assessment?
a. Direct Assessment of Functional Abilities (DAFA)
b. Lawton Instrumental Activities of Daily Living (IADL) scale
c. Barthel Index
d. Older Americans Resources and Services Multidimensional Functional
Assessment Questionnaire–IADL (OMFAQ-IADL)
ANS: C
The Barthel Index is used to assess ADLs. The other options are used to measure IADLs.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statemen
instrument is true?
a. The nurse uses direct observation to implement this tool.
b. The Lawton IADL instrument is designed as a self-report measure of performance
rather than ability.
c. This instrument is not useful in the acute hospital setting.
d. This tool is best used for those residing in an institutional setting.
ANS: B
The Lawton IADL instrument is designed as a self-report measure of performance rather than ability
demonstrating the ability to prepare food while a hospital inpatient, is often not feasible. Attention to
, 6. When using the various instruments to assess an older person’s ADLs, the nurse needs to remember t
instruments includes:
a. Reliability of the tools
b. Self- or proxy reporting of functional activities
c. Lack of confidentiality during the assessment
d. Insufficient details concerning the deficiencies identified
ANS: B
A disadvantage of many of the ADL and IADL instruments is the self- or proxy reporting of function
responses are not correct.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
7. A patient will be ready to be discharged from the hospital soon, and the patient’s family members are
the patient is able to walk safely outside alone. The nurse will perform which test to assess this?
a. Timed Up and Go Test
b. Performance Activities of Daily Living test
c. Physical Performance Test
d. Tinetti Gait and Balance Evaluation
ANS: A
The Timed Up and Go Test is a reliable and valid test to quantify functional mobility. The test is quic
no special equipment, and is appropriate to use in many settings including hospitals and clinics. This
to predict a person’s ability to go safely outside alone. The Performance Activities of Daily Living te
actually observing as a patient performs various ADLs. The Physical Performance Test assesses uppe
coarse motor activities, balance, mobility, coordination, and endurance. The Tinetti Gait and Balance
balance and provides information about fall risk. In a review of 17 functional balance tests, Langley a
recommended the Timed Up and Go Test as valid and reliable for the older adult population.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
8. The nurse is assessing the forms of support an older patient has before she is discharged. Which of th
source of support?
a. Local senior centre
b. Patient’s Medicare check
c. Meals on Wheels meal delivery service
d. Patient’s neighbour, who visits with her daily
ANS: D
Informal support includes family and long-time close friends and is usually provided free of charge. F
programs, such as social welfare and other social services, and health care delivery agencies, such as
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Psychosocial Integrity
9. An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his beds
she is his primary caregiver. The nurse should screen the wife using the:
a. Canadian Researchers at the End of Life Network (CARENET)
b. Duke Social Support and Stress Scale
c. Cornell Scale for Depression
d. Modified Caregiver Strain Index
ANS: D
The health and well-being of the older adult and caregiver are closely linked. Caregiver burden is the
person who cares for an older adult or for a person who is chronically ill or disabled. Caregiver stress
caregiving for a spouse, with almost half (47.2%) reporting distress. One formal screening tool is the
Index (Figure 31-5), which is used to identify caregivers of any age who need a more comprehensive
Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition
MULTIPLE CHOICE
1. The nurse is assessing an older adult’s functional ability. The nurse will need to determine the patien
a. Experience of the expected changes of aging.
b. Motivation to live independently
c. Level of cognition
d. Ability to perform activities necessary to live in modern society
ANS: D
Functional ability refers to one’s ability to perform activities necessary to live in modern society and
the telephone, or performing personal tasks, such as bathing and toileting.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
2. The nurse is preparing to perform a functional assessment with an older patient and knows that a goo
a. Observe the patient’s ability to perform the tasks
b. Ask the patient’s wife how he does when performing tasks
c. Review the medical record for information on the patient’s abilities
d. Ask the patient’s physician for information on the patient’s abilities
ANS: A
Two approaches are used to perform a functional assessment: (1) asking individuals about their abilit
(self-reports), or (2) actually observing their ability to perform the tasks. For persons with memory p
reporters (proxy reports), such as family members or caregivers, may be necessary, keeping in mind
overestimate or underestimate the person’s actual abilities.
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
3. The nurse needs to assess a patient’s ability to perform activities of daily living (ADLs) and should c
assessment?
a. Direct Assessment of Functional Abilities (DAFA)
b. Lawton Instrumental Activities of Daily Living (IADL) scale
c. Barthel Index
d. Older Americans Resources and Services Multidimensional Functional
Assessment Questionnaire–IADL (OMFAQ-IADL)
ANS: C
The Barthel Index is used to assess ADLs. The other options are used to measure IADLs.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
4. The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statemen
instrument is true?
a. The nurse uses direct observation to implement this tool.
b. The Lawton IADL instrument is designed as a self-report measure of performance
rather than ability.
c. This instrument is not useful in the acute hospital setting.
d. This tool is best used for those residing in an institutional setting.
ANS: B
The Lawton IADL instrument is designed as a self-report measure of performance rather than ability
demonstrating the ability to prepare food while a hospital inpatient, is often not feasible. Attention to
, 6. When using the various instruments to assess an older person’s ADLs, the nurse needs to remember t
instruments includes:
a. Reliability of the tools
b. Self- or proxy reporting of functional activities
c. Lack of confidentiality during the assessment
d. Insufficient details concerning the deficiencies identified
ANS: B
A disadvantage of many of the ADL and IADL instruments is the self- or proxy reporting of function
responses are not correct.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
7. A patient will be ready to be discharged from the hospital soon, and the patient’s family members are
the patient is able to walk safely outside alone. The nurse will perform which test to assess this?
a. Timed Up and Go Test
b. Performance Activities of Daily Living test
c. Physical Performance Test
d. Tinetti Gait and Balance Evaluation
ANS: A
The Timed Up and Go Test is a reliable and valid test to quantify functional mobility. The test is quic
no special equipment, and is appropriate to use in many settings including hospitals and clinics. This
to predict a person’s ability to go safely outside alone. The Performance Activities of Daily Living te
actually observing as a patient performs various ADLs. The Physical Performance Test assesses uppe
coarse motor activities, balance, mobility, coordination, and endurance. The Tinetti Gait and Balance
balance and provides information about fall risk. In a review of 17 functional balance tests, Langley a
recommended the Timed Up and Go Test as valid and reliable for the older adult population.
DIF: Cognitive Level: Understanding (Comprehension)
MSC: Client Needs: Health Promotion and Maintenance
8. The nurse is assessing the forms of support an older patient has before she is discharged. Which of th
source of support?
a. Local senior centre
b. Patient’s Medicare check
c. Meals on Wheels meal delivery service
d. Patient’s neighbour, who visits with her daily
ANS: D
Informal support includes family and long-time close friends and is usually provided free of charge. F
programs, such as social welfare and other social services, and health care delivery agencies, such as
DIF: Cognitive Level: Applying (Application)
MSC: Client Needs: Psychosocial Integrity
9. An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his beds
she is his primary caregiver. The nurse should screen the wife using the:
a. Canadian Researchers at the End of Life Network (CARENET)
b. Duke Social Support and Stress Scale
c. Cornell Scale for Depression
d. Modified Caregiver Strain Index
ANS: D
The health and well-being of the older adult and caregiver are closely linked. Caregiver burden is the
person who cares for an older adult or for a person who is chronically ill or disabled. Caregiver stress
caregiving for a spouse, with almost half (47.2%) reporting distress. One formal screening tool is the
Index (Figure 31-5), which is used to identify caregivers of any age who need a more comprehensive
