The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reports a decrease in energy and appetite. Which action should the nurse include during the assessment?
A.
Request to have the client lie as still as possible for the assessment.
B.
Ask the client how often episodes of sundowning are experienced.
C.
Question the client about the frequency of falls in recent months.
D.
Assist the client with clarifying values about end-of-life care
The Correct Answer and Explanation is:
The correct answer is C. Question the client about the frequency of falls in recent months.
Explanation
In performing a functional assessment on an older client who has experienced weight loss, decreased energy, and appetite, it is crucial to evaluate factors that may be impacting the client’s overall well-being and safety. Weight loss, coupled with decreased energy and appetite, can be indicative of several underlying issues, including physical or cognitive decline. One significant concern is the risk of falls, which is common in older adults due to various factors such as muscle weakness, balance issues, and changes in mobility.
Why Ask About Falls?
Falls are a major risk for older adults and can lead to serious injuries such as fractures or head trauma. They are often a result of decreased physical function or balance problems, which can be exacerbated by weight loss and reduced energy. By asking the client about the frequency of falls in recent months, the nurse can assess whether the client’s physical status has deteriorated, potentially revealing issues such as muscle weakness or balance impairment.
Additionally, understanding the frequency of falls can help the nurse identify any patterns or triggers, which can be crucial for planning appropriate interventions to prevent future falls. This information can lead to recommendations for physical therapy, home safety modifications, or other interventions designed to enhance stability and prevent falls.
Why Not the Other Options?
- A. Request to have the client lie as still as possible for the assessment: This action is not directly relevant to assessing functional decline related to weight loss, decreased energy, and appetite. It may be more appropriate for specific examinations or procedures rather than a functional assessment.
- B. Ask the client how often episodes of sundowning are experienced: Sundowning, a phenomenon where confusion or agitation worsens in the evening, is more relevant to cognitive assessment and dementia care rather than the immediate concerns of weight loss and decreased energy.
- D. Assist the client with clarifying values about end-of-life care: While end-of-life care is important, it is not the immediate focus when assessing functional status related to recent weight loss and energy decrease. It is more appropriate once immediate health and safety issues are addressed.
In summary, assessing the frequency of falls helps in evaluating the overall functional status of the client, which is critical in managing and mitigating the risks associated with the symptoms described.