Chapter 32: Functional Assessment of the Older Adult Flashcards
The nurse is assessing an older adults functional ability. Which definition correctly describes ones functional ability? Functional ability:
a. Is the measure of the expected changes of aging that one is experiencing.
b. Refers to the individuals motivation to live independently.
c. Refers to the level of cognition present in an older person.
d. Refers to ones ability to perform activities necessary to live in modern society.
d. Refers to ones ability to perform activities necessary to live in modern society.
RATIONALE: Functional ability refers to ones ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks such as bathing and toileting.
The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to:
a. Observe the patients ability to perform the tasks.
b. Ask the patients wife how he does when performing tasks.
c. Review the medical record for information on the patients abilities.
d. Ask the patients physician for information on the patients abilities.
a. Observe the patients ability to perform the tasks.
RATIONALE: Two approaches are used to perform a functional assessment: (1) asking individuals about their ability to perform the tasks (self-reports), or (2) actually observing their ability to perform the tasks. For persons with memory problems, the use of surrogate reporters (proxy reports), such as family members or caregivers, may be necessary, keeping in mind that they may either overestimate or underestimate the persons actual abilities.
The nurse needs to assess a patients ability to perform activities of daily living (ADLs) and should choose which tool for this assessment?
a. Direct Assessment of Functional Abilities (DAFA)
b. Lawton Instrumental Activities of Daily Living (IADL) scale
c. Barthel Index
d. Older Americans Resources and Services Multidimensional Functional Assessment QuestionnaireIADL (OMFAQ-IADL)
c. Barthel Index
RATIONALE: The Barthel Index is used to assess ADLs. The other options are used to measure IADLs.
The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true?
a. The nurse uses direct observation to implement this tool.
b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability.
c. This instrument is not useful in the acute hospital setting.
d. This tool is best used for those residing in an institutional setting.
b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability.
RATIONALE: The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. Direct testing is often not feasible, such as demonstrating the ability to prepare food while a hospital inpatient. Attention to the final score is less important than identifying a persons strengths and areas where assistance is needed. The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings. It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident.
The nurse is assessing an older adults advanced activities of daily living (AADLs), which would include:
a. Recreational activities.
b. Meal preparation.
c. Balancing the checkbook.
d. Self-grooming activities.
a. Recreational activities.
RATIONALE: AADLs are activities that an older adult performs such as occupational and recreational activities. Self- grooming activities are basic ADLs; meal preparation and balancing the checkbook are considered IADLs.
When using the various instruments to assess an older persons ADLs, the nurse needs to remember that a disadvantage of these instruments includes:
a. Reliability of the tools.
b. Self or proxy reporting of functional activities.
c. Lack of confidentiality during the assessment.
d. Insufficient details concerning the deficiencies identified.
b. Self or proxy reporting of functional activities.
RATIONALE: A disadvantage of many of the ADL and IADL instruments is the self or proxy reporting of functional activities. The other responses are not correct.
A patient will be ready to be discharged from the hospital soon, and the patients family members are concerned about whether the patient is able to walk safely outside alone. The nurse will perform which test to assess this?
a. Get Up and Go Test
b. Performance ADLs
c. Physical Performance Test
d. Tinetti Gait and Balance Evaluation
a. Get Up and Go Test
RATIONALE: The Get Up and Go Test is a reliable and valid test to quantify functional mobility. The test is quick, requires little training and no special equipment, and is appropriate to use in many settings including hospitals and clinics. This instrument has been shown to predict a persons ability to go safely outside alone. The Performance of ADLs test has a trained observer actually observing as a patient performs various ADLs. The Physical Performance Test assesses upper body fine motor and coarse motor activities, as well as balance, mobility, coordination, and endurance. The Tinetti Gait and Balance Evaluation assesses gait and balance and provides information about fall risk.
The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support?
a. Local senior center
b. Patients Medicare check
c. Meals on Wheels meal delivery service
d. Patients neighbor, who visits with her daily
d. Patients neighbor, who visits with her daily
RATIONALE: Informal support includes family and close, long-time friends and is usually provided free of charge. Formal supports include programs such as social welfare and other social service and health care delivery agencies such as home health care.
An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as:
a. Depression.
b. Weight gain.
c. Hypertension.
d. Social phobias.
a. Depression.
RATIONALE: Caregiver burden is the perceived strain by the person who cares for an older adult or for a person who is chronically ill or disabled. Caregiver burnout is linked to the caregivers ability to cope and handle stress. Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss. Screening caregivers for depression may also be appropriate.
During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterdays events. Which test is appropriate for assessing the patients mental status?
a. Geriatric Depression Scale, short form
b. Rapid Disability Rating Scale-2
c. Mini-Cog
d. Get Up and Go Test
c. Mini-Cog
RATIONALE: For nurses in various settings, cognitive assessments provide continuing comparisons to the individuals baseline to detect any acute changes in mental status. The Mini-Cog is a mental status test that tests immediate and delayed recall and visuospatial abilities. The Geriatric Depression Scale, short form, assesses for depression and changes in the level of depression, not mental status. The Rapid Disability Rating Scale-2 measures what the person can actually do versus what he or she could do, but not mental status. The Get Up and Go Test assesses functional mobility, not mental status.
An older patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time?
a. Lawton IADL instrument
b. Hospital Admission Risk Profile (HARP)
c. Mini-Cog
d. NEECHAM Confusion Scale
b. Hospital Admission Risk Profile (HARP)
RATIONALE: Hospital-acquired functional decline may occur within 2 days of a hospital admission. The HARP helps identify older adults who are at greatest risk of losing their ability to perform ADLs or mobility at this critical time. The Lawton IADL measures instrumental activities of daily living, which may be difficult to observe in the hospital setting. The Mini-Cog is an assessment of mental status. The NEECHAM Confusion Scale is used to assess for delirium.
During a functional assessment of an older persons home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards?
a. These low toilet seats are safe because they are nearer to the ground in case of falls.
b. Do you have a relative or friend who can help to install grab bars in your shower?
c. These small rugs are ideal for preventing you from slipping on the hard floor.
d. It would be safer to keep the lighting low in this room to avoid glare in your eyes.
b. Do you have a relative or friend who can help to install grab bars in your shower?
RATIONALE: Environmental hazards within the home can be a potential constraint on the older persons day-to-day functioning. Common environmental hazards, including inadequate lighting, loose throw rugs, curled carpet edges, obstructed hallways, cords in walkways, lack of grab bars in tub and shower, and low and loose toilet seats, are hazards that could lead to an increased risk of falls and fractures. Environmental modifications can promote mobility and reduce the likelihood of the older adult falling.
When beginning to assess a persons spirituality, which question by the nurse would be most appropriate?
a. Do you believe in God?
b. How does your spirituality relate to your health care decisions?
c. What religious faith do you follow?
d. Do you believe in the power of prayer?
b. How does your spirituality relate to your health care decisions?
RATIONALE: Open-ended questions provide a foundation for future discussions. The other responses are easily answered by one-word replies and are closed questions.
The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain. Which statement about pain and the older adult is true?
a. Pain is inevitable with aging.
b. Older adults with cognitive impairments feel less pain.
c. Alleviating pain should be a priority over other aspects of the assessment.
d. The assessment should take priority so that care decisions can be made.
c. Alleviating pain should be a priority over other aspects of the assessment.
RATIONALE: If the older adult is experiencing pain or discomfort, then the depth of knowledge gathered through the assessments will suffer. Alleviating pain should be a priority over other aspects of the assessment. Remembering that older adults with cognitive impairment do not feel less pain is paramount.
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say?
a. We will need to get a biopsy to determine the cause.
b. This is an overgrowth of hair and will go away in a few days.
c. Black, hairy tongue is a fungal infection caused by all the antibiotics you have received.
d. This is probably caused by the same bacteria you had in your lungs.
c. Black, hairy tongue is a fungal infection caused by all the antibiotics you have received.
RATIONALE: A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.
