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Which of the following are types of assessments that can be used to measure a client's functional ability?
Which of the following are types of assessments that can be used to measure a client's functional ability?
An individual's functional ability often increases due to alterations in health caused by an illness or accident.
An individual's functional ability often increases due to alterations in health caused by an illness or accident.
False
What is the primary purpose of the Katz Index of Independence in Activities of Daily Living?
What is the primary purpose of the Katz Index of Independence in Activities of Daily Living?
To assess a client's ability to perform basic activities of daily living (ADL) independently, such as bathing, dressing, toileting, transferring, continence, and feeding.
Which of the following factors is not assessed by the Braden Scale?
Which of the following factors is not assessed by the Braden Scale?
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What is the recommended bathing order when providing hygiene care to a client?
What is the recommended bathing order when providing hygiene care to a client?
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Nurses should always cut a client's toenails to ensure proper hygiene.
Nurses should always cut a client's toenails to ensure proper hygiene.
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Which type of bed bath involves bathing only body parts that would cause discomfort if left unbathed, such as hands, face, axilla, and perineal area?
Which type of bed bath involves bathing only body parts that would cause discomfort if left unbathed, such as hands, face, axilla, and perineal area?
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Which of the following is a type of bed bath that involves bathing from a bath basin or sink, with the client sitting in a chair?
Which of the following is a type of bed bath that involves bathing from a bath basin or sink, with the client sitting in a chair?
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Disposable bed baths offer an alternative because they are inconvenient, require long bathing time, and decrease client comfort.
Disposable bed baths offer an alternative because they are inconvenient, require long bathing time, and decrease client comfort.
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What is the most important safety consideration when making an occupied bed?
What is the most important safety consideration when making an occupied bed?
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What is the purpose of perineal care?
What is the purpose of perineal care?
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When performing perineal care for a client with a penis, the nurse should clean the tip from the urinary meatus outwards in a circular motion.
When performing perineal care for a client with a penis, the nurse should clean the tip from the urinary meatus outwards in a circular motion.
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What is the recommended frequency for wound assessment?
What is the recommended frequency for wound assessment?
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Which of the following is not a type of wound drainage?
Which of the following is not a type of wound drainage?
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The Braden Scale is used to assess a client's risk for pressure ulcers.
The Braden Scale is used to assess a client's risk for pressure ulcers.
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Medical device-related pressure injuries only occur on the skin.
Medical device-related pressure injuries only occur on the skin.
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Which of the following is a type of wound healing that occurs when the wound is closed, and edges are approximated?
Which of the following is a type of wound healing that occurs when the wound is closed, and edges are approximated?
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A wound healing by secondary intention is typically faster than a wound healing by primary intention.
A wound healing by secondary intention is typically faster than a wound healing by primary intention.
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What is the purpose of a wound dressing?
What is the purpose of a wound dressing?
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What are the three main categories of prescribed diets?
What are the three main categories of prescribed diets?
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A low-fiber diet is recommended for long-term use for clients with chronic constipation.
A low-fiber diet is recommended for long-term use for clients with chronic constipation.
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What is the main goal of medical nutritional therapy?
What is the main goal of medical nutritional therapy?
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Clients with celiac disease must eat a gluten-free diet.
Clients with celiac disease must eat a gluten-free diet.
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A low-fiber diet is recommended for clients with diverticulitis.
A low-fiber diet is recommended for clients with diverticulitis.
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What are the two types of enteral nutrition?
What are the two types of enteral nutrition?
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Enteral nutrition can be administered via the nasogastric, nasoduodenal, or nasojejunal route, but not through gastric tubes.
Enteral nutrition can be administered via the nasogastric, nasoduodenal, or nasojejunal route, but not through gastric tubes.
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Enteral nutrition is typically preferred over parenteral nutrition because it has fewer complications.
Enteral nutrition is typically preferred over parenteral nutrition because it has fewer complications.
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A continuous infusion is typically used for critically ill clients.
A continuous infusion is typically used for critically ill clients.
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Which type of enteral feeding involves administering a large volume of formula over a short period of time (typically 30-60 minutes)?
Which type of enteral feeding involves administering a large volume of formula over a short period of time (typically 30-60 minutes)?
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When administering enteral nutrition, it's vital to check the tube placement only once, before the first feeding.
When administering enteral nutrition, it's vital to check the tube placement only once, before the first feeding.
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When administering enteral feeding, the formula should be warmed in the microwave.
When administering enteral feeding, the formula should be warmed in the microwave.
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It's essential to monitor for signs of aspiration during enteral feeding.
It's essential to monitor for signs of aspiration during enteral feeding.
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Formula bags and administration tubing used for enteral feeding should be changed every 48 hours.
Formula bags and administration tubing used for enteral feeding should be changed every 48 hours.
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What are the two main types of parenteral nutrition?
What are the two main types of parenteral nutrition?
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TPN is often used for short-term therapy, typically lasting 3-5 days.
TPN is often used for short-term therapy, typically lasting 3-5 days.
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PPN typically contains more than 10% dextrose.
PPN typically contains more than 10% dextrose.
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What are the three main components of parenteral nutrition?
What are the three main components of parenteral nutrition?
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The nurse should always check for client allergies before administering parenteral nutrition.
The nurse should always check for client allergies before administering parenteral nutrition.
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Parenteral nutrition solutions must be warmed to 98.6 degrees Fahrenheit before administration.
Parenteral nutrition solutions must be warmed to 98.6 degrees Fahrenheit before administration.
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A micron filter is needed on the intravenous administration tubing for administering both peripheral and central parenteral nutrition.
A micron filter is needed on the intravenous administration tubing for administering both peripheral and central parenteral nutrition.
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When administering parenteral nutrition, the nurse should monitor the client's weight every other day.
When administering parenteral nutrition, the nurse should monitor the client's weight every other day.
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A client’s blood glucose levels are typically monitored hourly during parenteral nutrition.
A client’s blood glucose levels are typically monitored hourly during parenteral nutrition.
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Clients receiving enteral nutrition should be positioned with the head of the bed flat during feeding.
Clients receiving enteral nutrition should be positioned with the head of the bed flat during feeding.
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What are some of the potential complications of enteral nutrition?
What are some of the potential complications of enteral nutrition?
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Clients with a history of aspiration pneumonia should be referred to a speech-language pathologist (SLP) for further screening and diagnosis.
Clients with a history of aspiration pneumonia should be referred to a speech-language pathologist (SLP) for further screening and diagnosis.
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What are the different levels of liquids in the dysphasia diet?
What are the different levels of liquids in the dysphasia diet?
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Nurses can delegate the administration of enteral feeding to unlicensed assistive personnel (UAP) but they must ensure the client can open their mouth and stick out their tongue.
Nurses can delegate the administration of enteral feeding to unlicensed assistive personnel (UAP) but they must ensure the client can open their mouth and stick out their tongue.
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For clients with dysphasia, it is recommended to use a straw for drinking.
For clients with dysphasia, it is recommended to use a straw for drinking.
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When performing a bedside swallow assessment, the nurse should ask the client to drink 3 ounces of water with a straw.
When performing a bedside swallow assessment, the nurse should ask the client to drink 3 ounces of water with a straw.
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A client with a history of coughing or gagging with food or fluid intake should be placed on NPO status until further evaluation is completed.
A client with a history of coughing or gagging with food or fluid intake should be placed on NPO status until further evaluation is completed.
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Small-bore feeding tubes are typically used for gastric decompression.
Small-bore feeding tubes are typically used for gastric decompression.
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When administering enteral feeding, it is recommended to administer medications with the feeding, to prevent over-medication.
When administering enteral feeding, it is recommended to administer medications with the feeding, to prevent over-medication.
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A clear liquid diet excludes tea, coffee, clear broth, and carbonated clear beverages.
A clear liquid diet excludes tea, coffee, clear broth, and carbonated clear beverages.
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The full liquid diet is not nutritionally complete and should not be used for extended periods.
The full liquid diet is not nutritionally complete and should not be used for extended periods.
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Clients with inflammatory bowel diseases should avoid all trigger foods such as alcohol and caffeine, to manage their condition.
Clients with inflammatory bowel diseases should avoid all trigger foods such as alcohol and caffeine, to manage their condition.
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A mechanical soft diet restricts all foods that require minimal chewing before swallowing.
A mechanical soft diet restricts all foods that require minimal chewing before swallowing.
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A client with diverticulitis should eat a low-fiber diet until the inflammation resolves.
A client with diverticulitis should eat a low-fiber diet until the inflammation resolves.
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Clients with diabetes should avoid using artificial sweeteners.
Clients with diabetes should avoid using artificial sweeteners.
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Consuming alcohol is generally discouraged for clients with cardiovascular disease and should be avoided.
Consuming alcohol is generally discouraged for clients with cardiovascular disease and should be avoided.
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Clients with cancer should avoid fatty foods and increase fiber intake.
Clients with cancer should avoid fatty foods and increase fiber intake.
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Clients with HIV should avoid raw fruits and vegetables, undercooked meats, and eggs to minimize the risk of foodborne bacteria.
Clients with HIV should avoid raw fruits and vegetables, undercooked meats, and eggs to minimize the risk of foodborne bacteria.
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When assisting a client with oral feeding, it’s essential to elevate the head of the bed at least 30 degrees, to reduce the risk of aspiration.
When assisting a client with oral feeding, it’s essential to elevate the head of the bed at least 30 degrees, to reduce the risk of aspiration.
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NG tube insertion can be safely delegated to unlicensed assistive personnel (UAP).
NG tube insertion can be safely delegated to unlicensed assistive personnel (UAP).
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When administering medication through an NG tube, the nurse should pause the enteral feeding for at least 30 minutes before the first medication administration
When administering medication through an NG tube, the nurse should pause the enteral feeding for at least 30 minutes before the first medication administration
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NG tubes should be removed after 3 weeks.
NG tubes should be removed after 3 weeks.
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Study Notes
Functional Ability Assessment
- Measures a client's ability to complete daily tasks.
- Measures the impact of illness on self-care.
- Determines the level of assistance needed.
- Monitors changes in functional ability due to chronic health alterations.
Types of Assessments
- Social
- Economic
- Mental health
- Physical health
- Self-care capacity
Functional Ability
- An individual's functional ability often decreases due to illness or accident.
- The responsibility of nurses is to work with clients to determine their level of functional ability and plan interventions that promote independence.
- Tools to assess functional ability include:
- Katz Index of Independence in Activities of Daily Living (ADLs): assesses bathing, dressing, toileting, mobility, continence, and feeding. One point is given for independent task completion and no points if assistance is needed. Higher scores indicate greater independence.
- Lawton Instrumental Activities of Daily Living (IADLs): assesses more complex daily tasks such as using a phone, managing medications, and handling finances. Higher scores indicate greater independence.
- Braden Scale: measures risk for pressure wounds based on sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scores of 16 or less are considered at risk. Lower scores indicate higher risk.
Hygiene & Tissue Integrity
- Bathing Order: Provides a detailed sequence for hygiene care, including specific instructions for eye, face, arms, chest, abdomen, legs, and perineal care.
- Foot Care: Instructions emphasize inspecting feet, washing them, drying thoroughly, applying lotion, and considerations for individuals with decreased circulation.
- Eye Care: Detailed steps for eye hygiene are presented.
- Oral Care: Instructions and procedures for oral care are provided.
- Includes hygiene tasks and the tools to assess functional abilities.
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Description
This quiz evaluates your understanding of functional ability assessments, their various types, and their significance in nursing care. You'll learn how to measure a client's independence and determine the necessary level of assistance. Explore tools like the Katz Index and Lawton IADLs that are crucial for assessing daily living activities.
