NR224- Funds: Skills- Exam 2 Review UPDATED ACTUAL Questions and
CORRECT Answers
Definition:
-Functional Assessment measures the client's ability to perform tasks and activities
associated with daily living, helping determine their ability to care for themselves at
home.
Ty pes of Activities:
-ADLs (Activities of Daily Living): Basic tasks like bathing, dressing, toileting, mobility,
continence, and feeding.
Functional Assessment in Nursing -IADLs (Instrumental Activities of Daily Living): More complex tasks like shopping,
meal preparation, home maintenance, laundry, transportation, medication
management, and financial handling.
Alterations in Functional Ability:
-Functional ability may decrease due to illness or injury.
-Nurses must assess and modify interventions to meet the client's needs.
-The goal is to promote independence while ensuring the client receives necessary
assistance.
, Katz Index of Independence in Activities of Daily Living (ADLs):
-Purpose: Assesses the client’s ability to perform basic ADLs, including bathing,
dressing, toileting, transferring (mobility), continence, and feeding.
Scoring:
-1 Point: Able to perform the task independently.
-0 Points: Needs assistance with the task.
Interpretation:
-A higher score indicates greater independence.
-A lower score indicates more dependence on others.
Functional Assessment Tools in Nursing
Lawton Instrumental Activities of Daily Living (IADLs) Scale:
-Purpose: Evaluates the client’s ability to perform more complex daily activities, such
as using a telephone, shopping, preparing food, housekeeping, laundry,
transportation, managing medications, and handling finances.
Scoring:
-1 Point: Able to complete the activity independently.
-0 Points: Requires assistance with the activity.
Interpretation:
-A higher score indicates greater independence in complex daily activities.
-A lower score indicates more dependence on others.
Purpose: Assesses risk for pressure wounds.
Components:
-Sensory Perception: Response to pressure-
related discomfort.
-Moisture: Skin exposure to moisture.
-Activity: Level of physical activity.
-Mobility: Ability to change and control body
Braden Scale position.
-Nutrition: Intake of food and liquids.
-Friction and Shear: Impact of movement against
surfaces.
Risk Scores:
-15–16 = Low risk
-13–14 = Moderate risk
-12 or less = High risk
Hygiene and Skin Integrity:
-Hygiene practices affect skin health.
-During hygiene care, assess for skin and musculoskeletal abnormalities and self-
care deficits.
Influencing Factors:
-Body Image
-Personal Preferences
Factors Influencing Hygiene in Nursing
-Health Beliefs & Motivation
Care
-Socioeconomic Status
-Culture
-Age
-Gender Identities
Nurse’s Role:
-Educate, set goals, and collaborate with UAP by delegating hygiene activities
appropriately.
, Privacy:
-Close curtain or door.
-Use proper draping to expose only necessary areas.
Safety:
-Use side rails for dependent or unconscious patients.
-Ensure nurse call system is within reach.
Warmth:
-Ensure room and water temperature are comfortable.
Best Practices for Hygiene Care -Check water temperature on the inner wrist.
Promote Independence:
-Encourage client participation in bathing.
-Assist as needed.
Anticipate Needs:
-Prepare fresh clothing, hygiene products, and linens at bedside.
Standard Precautions:
-Apply standard precautions or isolation protocols if necessary.
1. Ey es
-Wear clean gloves; assess the eye for discharge, bruising, or inflammation.
-Wipe the upper lid from the medial canthus outward with a clean, damp washcloth.
-Use a different portion of the washcloth for the other eye.
2. Face, Head, and Neck
-Use the washcloth from the eyes if clean; otherwise, use a fresh one.
-Use a wet washcloth with mild or no soap as needed.
-Gently cleanse the external ears, avoiding the ear canal.
-Finish with the neck.
3. Arms, Chest, and Hands
-Cleanse both arms first, then the chest and underarms.
-Finish with the hands and nails.
Correct Order of Bathing/Hygiene Care
4. Abdomen and Legs
-Change washcloths if soiled.
-Wash the abdomen and legs, avoiding the perineum.
5. Perineum
-Cleanse the perineum with mild soap and warm water.
-Change the washcloth after cleaning.
6. Back
-Use a clean washcloth; perform long, slow, gliding strokes to relax the client.
7. Buttocks and Anus
-Clean the buttocks first.
-Inform the client before washing their anus.
CORRECT Answers
Definition:
-Functional Assessment measures the client's ability to perform tasks and activities
associated with daily living, helping determine their ability to care for themselves at
home.
Ty pes of Activities:
-ADLs (Activities of Daily Living): Basic tasks like bathing, dressing, toileting, mobility,
continence, and feeding.
Functional Assessment in Nursing -IADLs (Instrumental Activities of Daily Living): More complex tasks like shopping,
meal preparation, home maintenance, laundry, transportation, medication
management, and financial handling.
Alterations in Functional Ability:
-Functional ability may decrease due to illness or injury.
-Nurses must assess and modify interventions to meet the client's needs.
-The goal is to promote independence while ensuring the client receives necessary
assistance.
, Katz Index of Independence in Activities of Daily Living (ADLs):
-Purpose: Assesses the client’s ability to perform basic ADLs, including bathing,
dressing, toileting, transferring (mobility), continence, and feeding.
Scoring:
-1 Point: Able to perform the task independently.
-0 Points: Needs assistance with the task.
Interpretation:
-A higher score indicates greater independence.
-A lower score indicates more dependence on others.
Functional Assessment Tools in Nursing
Lawton Instrumental Activities of Daily Living (IADLs) Scale:
-Purpose: Evaluates the client’s ability to perform more complex daily activities, such
as using a telephone, shopping, preparing food, housekeeping, laundry,
transportation, managing medications, and handling finances.
Scoring:
-1 Point: Able to complete the activity independently.
-0 Points: Requires assistance with the activity.
Interpretation:
-A higher score indicates greater independence in complex daily activities.
-A lower score indicates more dependence on others.
Purpose: Assesses risk for pressure wounds.
Components:
-Sensory Perception: Response to pressure-
related discomfort.
-Moisture: Skin exposure to moisture.
-Activity: Level of physical activity.
-Mobility: Ability to change and control body
Braden Scale position.
-Nutrition: Intake of food and liquids.
-Friction and Shear: Impact of movement against
surfaces.
Risk Scores:
-15–16 = Low risk
-13–14 = Moderate risk
-12 or less = High risk
Hygiene and Skin Integrity:
-Hygiene practices affect skin health.
-During hygiene care, assess for skin and musculoskeletal abnormalities and self-
care deficits.
Influencing Factors:
-Body Image
-Personal Preferences
Factors Influencing Hygiene in Nursing
-Health Beliefs & Motivation
Care
-Socioeconomic Status
-Culture
-Age
-Gender Identities
Nurse’s Role:
-Educate, set goals, and collaborate with UAP by delegating hygiene activities
appropriately.
, Privacy:
-Close curtain or door.
-Use proper draping to expose only necessary areas.
Safety:
-Use side rails for dependent or unconscious patients.
-Ensure nurse call system is within reach.
Warmth:
-Ensure room and water temperature are comfortable.
Best Practices for Hygiene Care -Check water temperature on the inner wrist.
Promote Independence:
-Encourage client participation in bathing.
-Assist as needed.
Anticipate Needs:
-Prepare fresh clothing, hygiene products, and linens at bedside.
Standard Precautions:
-Apply standard precautions or isolation protocols if necessary.
1. Ey es
-Wear clean gloves; assess the eye for discharge, bruising, or inflammation.
-Wipe the upper lid from the medial canthus outward with a clean, damp washcloth.
-Use a different portion of the washcloth for the other eye.
2. Face, Head, and Neck
-Use the washcloth from the eyes if clean; otherwise, use a fresh one.
-Use a wet washcloth with mild or no soap as needed.
-Gently cleanse the external ears, avoiding the ear canal.
-Finish with the neck.
3. Arms, Chest, and Hands
-Cleanse both arms first, then the chest and underarms.
-Finish with the hands and nails.
Correct Order of Bathing/Hygiene Care
4. Abdomen and Legs
-Change washcloths if soiled.
-Wash the abdomen and legs, avoiding the perineum.
5. Perineum
-Cleanse the perineum with mild soap and warm water.
-Change the washcloth after cleaning.
6. Back
-Use a clean washcloth; perform long, slow, gliding strokes to relax the client.
7. Buttocks and Anus
-Clean the buttocks first.
-Inform the client before washing their anus.
