Question 1

When using the various instruments to assess an older person's ADLs, what should the nurse keep in mind as a disadvantage of these instruments?

Accepted Answer

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.

Question 2

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

Accepted Answer

Open-ended questions provide a foundation for future discussions. The other responses are easily answered by one-word replies and are closed questions.

Question 3

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. Which tool or test would be best to assess this?

Accepted Answer

The Timed Up and Go Test (TUG) 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. The practitioner observes and times the patient as he or she rises from a chair, walks 10 feet, turns, walks back to the chair, and sits down. Factors to note are sitting balance, transferring from sitting to standing, pace and stability of gait, ability to turn without staggering, and sitting back down in the chair. An older person who takes longer than 12 seconds to complete the test is at high risk for falling and may need further evaluation. 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 person's 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 Katz Index of ADL is based on the concept of physical disability and measures physical function in older adults and the chronically ill. The Katz ADL is valuable for planning specific types of assistance that the older person may need, rather than determining the most suitable living situation. The Geriatric Depression Test is a tool to screen for depression, not physical mobility.

Question 4

During a routine well-person checkup, the daughter of an older patient mentions to the nurse notices she has noticed her mother is less attentive and sometimes unable to recall events from a previous day. The daughter said this does not happen all the time, but that she has noticed it twice in the last month. Which test would be best to assess this patient's mental status?

Accepted Answer

While both the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) assess cognition and can be completed in approximately 10 minutes by pen and paper only, the MoCA is more sensitive in detecting mild cognitive impairment and includes assessments of frontal executive function and spatial attention. The Timed Up and Go Test (TUG) is a reliable and valid test to quantify functional mobility, not cognitive ability. The Geriatric Depression Scale, short form, assesses for depression and changes in the level of depression, not mental status.

Question 5

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

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.

Question 6

The nurse needs to determine an older adult's competence and maintenance of life skills in order to determine the most suitable living situation for them. What tool should the nurse use for this assessment?

Accepted Answer

The Lawton IADL scale was originally developed to determine competence and maintenance of life skills such as shopping, cooking, and managing finances in a meaningful way. IADLS are a prerequisite for independent living and contains 8 items: use of telephone, shopping, meal preparation, housekeeping, laundry, transportation, self-medication, and management of finances. It is a self-report measure of performance rather than ability and is useful for discharge planning in acute hospital settings and for ongoing measurement of function in outpatient settings. It would not be useful for those residing in institutional settings because many of the tasks are already being managed for the resident. The Katz Index of ADL is based on the concept of physical disability and measures physical function in older adults and the chronically ill. The Katz ADL is valuable for planning specific types of assistance that the older person may need, rather than determining the most suitable living situation. The Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) are cognitive assessments.

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. What should the nurse assess the patient's wife for as a sign of possible caregiver burnout?

Accepted Answer

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 caregiver's 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.

Question 8

The nurse is preparing to perform a functional assessment of an older patient. What is an appropriate approach for the nurse to take?

Accepted Answer

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 people 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 person's actual abilities.

Question 9

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

Accepted Answer

Typically, IADL tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation. The other options listed are ADLs r/t self-care.

Question 10

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

Accepted Answer

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.

Question 11

The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability?

Accepted Answer

Functional ability refers to one's 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.

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

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 person's 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.

Question 13

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

Environmental hazards within the home can be a potential constraint on the older person's 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 for falls and fractures. Environmental modifications can promote mobility and reduce the likelihood of the older adult falling.

Quiz 32: Functional Assessment of the Older Adult