Author Question: The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the ... (Read 83 times)

Alygatorr01285 · **on:** Jul 22, 2018

The nurse is assessing a patient with a mobility dysfunction and wants to gain insight into the patient's functional ability. What question would be the most appropriate?

a. Are you able to shop for yourself?
b. Do you use a cane, walker, or wheelchair to ambulate?
c. Do you know what today's date is?
d. Were you sad or depressed more than once in the last 3 days?

Question 2

The nurse is developing an interdisciplinary plan of care using the Roper-Logan-Tierney Model of Nursing for a patient who is currently unconscious. Which interventions would be most critical to developing a plan of care for this patient?

a. Eating and drinking, personal cleansing and dressing, working and playing
b. Toileting, transferring, dressing, and bathing activities
c. Sleeping, expressing sexuality, socializing with peers
d. Maintaining a safe environment, breathing, maintaining temperature

CharlieArnold · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
Do you use a cane, walker, or wheelchair to ambulate? will assist the nurse in determining the patient's ability to perform self-care activities. A nutritional health risk assessment is not the functional assessment. Knowing the date is part of a mental status exam. Assessing sadness is a question to ask in the depression screening.

Answer to Question 2

ANS: D
The most critical aspects of care for an unconscious patient are safe environment, breathing, and temperature. Eating and drinking are contraindicated in unconscious patients. Toileting, transferring, dressing, and bathing activities are BADLs. Sleeping, expressing sexuality, and socializing with peers are a part of the Roper-Logan-Tierney Model of Nursing; however, these are not the most critical for developing the plan of care in an unconscious patient.