The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?
A.
Question the client about the frequency of falls in recent months.
B.
Request to have the client lie as still as possible for the assessment.
C.
Assist the client with clarifying values about end-of-life care options.
D.
Ask the client how often episodes of sundowning are experienced.
The Correct Answer and Explanation is:
The correct answer is A. Question the client about the frequency of falls in recent months.
Explanation:
When performing a functional assessment on an older adult client who reports decreased activity due to reduced energy and strength, it’s crucial to assess various aspects of their functional status to identify any underlying issues. One significant area to evaluate is the client’s history of falls.
Falls History: Older adults are at a higher risk of falling due to a combination of factors, including reduced strength, balance issues, and medications that may affect their stability. Falls can be indicative of functional decline, unsafe environments, or other health issues. By asking about the frequency of falls, the nurse can gather important information about the client’s mobility, balance, and overall safety. Understanding the client’s fall history helps in assessing their risk for future falls and planning appropriate interventions to prevent them. It also provides insight into their functional abilities and the impact of their reported decreased activity.
Why Not the Other Options?
- B. Request to have the client lie as still as possible for the assessment: While this may be relevant for specific assessments, it does not directly address the functional issues related to decreased activity. The focus should be on understanding how the client’s physical abilities impact their daily life.
- C. Assist the client with clarifying values about end-of-life care options: This is an important aspect of care but is not directly related to assessing the functional impact of decreased activity and strength. This option pertains more to advanced care planning rather than functional assessment.
- D. Ask the client how often episodes of sundowning are experienced: Sundowning refers to symptoms of confusion or agitation that occur in the late afternoon or evening and is more relevant to cognitive assessments rather than functional assessments of activity and strength. It does not address the physical aspects of decreased activity and strength.
In summary, questioning the client about the frequency of falls provides valuable information about their current functional status and helps in identifying areas where interventions may be needed to improve safety and enhance quality of life.