Author Question: A nurse assesses a 91-year-old client in long-term care healing from bilateral broken legs caused in ... (Read 78 times)

olgavictoria · **on:** Jul 11, 2018

A nurse assesses a 91-year-old client in long-term care healing from bilateral broken legs caused in a fall. Today, the client developed new onset confusion and combativeness.

Which of the factors must the nurse investigate as a source of this mental status state? (Select all that apply.)

A) Social separation
B) Hyponatremia
C) Medication interactions
D) Positional pain
E) Urinary tract infection

Question 2

Assessment of an older adult's ADLs addresses parameters such as mobility, dressing, and elimination. In addition to these, which of the following categories should the functional assessment also include?

A) Pain
B) Mental status
C) Previous medical history
D) Integumentary assessment

lkoler · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

Ans: B, C, E
Sodium level, medications, and urinary tract infections can each lead to confusion and combativeness. While pain and social separation may be associated with confusion, they are unlikely to be the root cause of these new onset issues.

Answer to Question 2

Ans: B
A brief mental status assessment is included on the ADL form. Including mental status in the functional assessment rather than using a separate mental status assessment tool reinforces the fact that cognitive function is an integral component of ADLs. In addition, it helps to determine whether ADL impairments are attributable, at least in part, to cognitive impairments, rather than primarily to physical limitations. Pain, medical history, and integument are all relevant assessment parameters, but none is explicitly included in a functional assessment.