Question 1

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.The nurse will need to complete a comprehensive assessment of the patient's: (Select all that apply.)

Accepted Answer

A)  Cognition
B)  Physical performance
C)  Weight-loss strategies
D)  Social networks
E)  Functional abilityF) Artistic ability A, B, D, E

Question 2

When using the various instruments to assess an older person's ADLs, the nurse needs to remember that a disadvantage of these instruments includes:

Accepted Answer

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

Question 3

When beginning to assess a person's spirituality, which question by the nurse would be most appropriate?

Accepted Answer

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

Question 4

The nurse is assessing an older adult's advanced activities of daily living (AADLs), which would include:

Accepted Answer

A)  Recreational activities
B)  Meal preparation
C)  Balancing the chequebook
D)  Self-grooming activities

Question 5

A 68-year-old patient with dementia is requesting information about medical assistance in dying.The nurse informs the patient that to be eligible for medical assistance in dying, the individual must: (Select all that apply.)

Accepted Answer

A)  Be 18 years of age or older
B)  Have someone make the request for the patient
C)  Have an irremediable medical condition
D)  Have the request in writing
E)  Be capable of giving informed consent

Question 6

A patient will be ready to be discharged from the hospital soon, and the patient's family members are concerned about whether the patient is able to walk safely outside alone.The nurse will perform which test to assess this?

Accepted Answer

A)  Timed Up and Go Test
B)  Performance Activities of Daily Living test
C)  Physical Performance Test
D)  Tinetti Gait and Balance Evaluation

Question 7

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 screen the wife using the:

Accepted Answer

A)  Canadian Researchers at the End of Life Network (CARENET) 
B)  Duke Social Support and Stress Scale
C)  Cornell Scale for Depression
D)  Modified Caregiver Strain Index

Question 8

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?

Accepted Answer

A)  Local senior centre
B)  Patient's Medicare check
C)  Meals on Wheels meal delivery service
D)  Patient's neighbour, who visits with her daily

Question 9

During a health history interview with an 88-year-old female patient and daughter who is the caregiver, the nurse notes that the daughter appears stressed and her responses are abrupt.The nurse uses STOPHARM to:

Accepted Answer

A)  Assess for physical and cognitive changes
B)  Determine potential elder abuse
C)  Measure physical function
D)  Evaluate support and stress

Question 10

The nurse needs to assess a patient's ability to perform activities of daily living (ADLs) and should choose which tool for this assessment?

Accepted Answer

A)  Direct Assessment of Functional Abilities (DAF
A)  
B)  Lawton Instrumental Activities of Daily Living (IADL)  scale
C)  Barthel Index
D)  Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL (OMFAQ-IADL)

Question 11

The nurse is preparing to perform a functional assessment with an older patient and knows that a good approach would be to:

Accepted Answer

A)  Observe the patient's ability to perform the tasks
B)  Ask the patient's wife how he does when performing tasks
C)  Review the medical record for information on the patient's abilities
D)  Ask the patient's physician for information on the patient's abilities

Question 12

The nurse is preparing to use the Lawton IADL instrument as part of an assessment.Which statement about the Lawton IADL instrument is true?

Accepted Answer

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.

Question 13

The nurse is assessing an older adult's functional ability.The nurse will need to determine the patient's:

Accepted Answer

A)  Experience of the expected changes of aging.
B)  Motivation to live independently
C)  Level of cognition
D)  Ability to perform activities necessary to live in modern society

Question 14

During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events.Which test is appropriate for assessing the patient's mental status?

Accepted Answer

A)  Geriatric Depression Scale, short form
B)  Rapid Disability Rating Scale-2
C)  Mini-Cog
D)  Timed Up and Go Test

Question 15

During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards?

Accepted Answer

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 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."

Question 16

The nurse is working with the older adult population and recognizes that polypharmacy can increase the risk for the older adult for:

Accepted Answer

A)  Increased sexuality
B)  Reduction of falls
C)  Decrease in functional ability
D)  Improved cognition

Question 17

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?

Accepted Answer

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.

Question 18

The nurse is assessing the abilities of an older adult.Which activities are considered IADLs? (Select all that apply.)

Accepted Answer

A)  Feeding oneself
B)  Preparing a meal
C)  Balancing the chequebook
D)  Walking
E)  ToiletingF) Grocery shopping

Exam 31: Functional Assessment of the Older Adult