Functional Ability & Status
While assessing an 82-year-old patient recovering from hip surgery, the nurse observes she can bathe and dress herself but tires easily. The nurse is evaluating which aspect of her function?
A. Functional performance
B. Functional ability
C. Functional dependence
D. Cognitive adaptation
B. functional ability
Rationale: Functional ability is the capacity to perform self-care and daily tasks, even if assistance is occasionally needed
Before discharge, a nurse assesses a patient’s ability to perform ADLs for future comparison. What is being established?
A. Functional baseline
B. Nursing diagnosis
C. Activity tolerance
D. Care plan
A – Functional baseline
Rationale: A baseline provides a starting point to detect improvement or decline.
A stroke patient is assessed on bathing, dressing, toileting, transferring, continence, and feeding. Which tool is used?
A. Lawton IADL
B. Katz ADL
C. Barthel Index
D. TUG Test
B – Katz ADL
Rationale: Katz Index evaluates six basic self-care activities.
The nurse is assessing the abilities of an older adult. Which activities are considered IADLs? Select all that apply.
a)Feeding oneself
b)Preparing a meal
c) Balancing a checkbook
d) Walking
e) Toileting
f) Grocery shopping
b) preparing a meal
c) balancing a check book
f) grocery shopping
Rationale: Typically, IADL tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation. The other options listed are ADLs related to self-care.
The nurse notes cluttered hallways and dim lighting in an elderly client’s home. Which aspect is being assessed?
A. Psychosocial health
B. Environmental safety
C. Functional status
D. Spiritual support
B – Environmental safety
Rationale: Safety checks identify fall risks and accessibility barriers.
Functional assessment evaluates physical, cognitive, psychological, and _____.
A. Spiritual function
B. Emotional function
C. Social function
D. Environmental function
C. Social Function
A daughter caring for her mother appears exhausted and tearful. What should the nurse assess next?
A. Coping style
B. Caregiver burden
C. Sleep pattern
D. Nutritional status
B – Caregiver burden
Rationale: Caregiver stress can lead to burnout and reduced quality of care.
An older adult can dress independently but no longer shops or manages finances. Which tool best evaluates these?
A. Katz ADL
B. Tinetti Test
C. Lawton IADL
D. Braden Scale
C – Lawton IADL
Rationale: Lawton measures complex community-living skills.
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.
b) Meal preparation
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 client struggles to rise from a low chair; the nurse suggests one with arms and proper height. This supports:
A. Rest and comfort
B. Social interaction
C. Mobility independence
D. Energy conservation
C – Mobility independence
Rationale: Proper furniture promotes safe transfers and self-care.
A nurse observes a client who says she “can walk fine,” but needs assistance to transfer from bed to chair. What concept does this difference between reported and observed performance demonstrate?
A. Cognitive decline
B. Functional capacity
C. Functional status
D. Psychosocial adaptation
C. functional status
Rationale: Functional status refers to actual performance of activities in real settings, not what the client reports.
The nurse encourages a post-op knee patient to dress independently with adaptive tools. What is the goal?
A. Increase strength
B. Promote independence
C. Prevent injury
D. Maintain safety only
B – Promote independence
Rationale: Supporting autonomy maintains dignity and functional recovery.
The nurse times how long a client takes to stand, walk 10 feet, turn, and sit again. What test is this?
A. Berg Balance
B. TUG Test
C. Mini-Mental
D. Morse Fall Scale
B – TUG Test
Rationale: The Timed Up and Go test assesses mobility and fall risk.
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
A patient with dementia fluctuates in attention throughout the day. When should the nurse perform a functional assessment?
A. Anytime of day
B. When family is present
C. When most alert
D. Before medication administration
C – When most alert
Rationale: Optimal performance times give the most accurate results.
An older adult demonstrates poor decision-making when managing medications but maintains strong mobility and endurance. Which two domains of function should the nurse document as affected and intact?
A. Cognitive (affected), physical (intact)
B. Psychological (affected), physical (intact)
C. Physical (affected), social (intact)
D. Cognitive (intact), psychological (affected)
cognitive function (affected) and physical function (intact)
Rationale: Difficulty with decision-making and judgment reflects cognitive decline, not physical limitation.
A nurse emphasizes a patient’s strengths rather than limitations. What approach is used?
A. Strengths-based
B. Task-focused
C. Risk-reduction
D. Deficit-based
A – Strengths-based
Rationale: Emphasizing what patients can do promotes confidence and engagement.
A client takes 14 seconds on the TUG test. What should the nurse do next?
A. Encourage more walking
B. Initiate fall prevention plan
C. Document as normal
D. Reassess in a month
B – Initiate fall prevention
Rationale: Times >12 seconds indicate increased fall risk.
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 client on multiple medications reports dizziness and unsteady gait. What is the likely cause?
A. Malnutrition
B. Polypharmacy
C. Cognitive decline
D. Dehydration
B – Polypharmacy
Rationale: Multiple drugs increase confusion and fall risk.
A patient reports difficulty paying bills and organizing medications. What type of decline is the nurse recognizing?
A. ADL impairment
B. Sensory loss
C. IADL decline
D. Cognitive enhancement
C. IADL decline
Rationale: Managing finances and medications are instrumental ADLs that often decline before basic ADLs.
The nurse integrates information about client ability, caregiver health, home safety, and spirituality. What plan results?
A. Short-term rehab plan
B. Holistic functional care plan
C. Medical-surgical plan
D. Acute care pathway
B – Holistic functional care plan
Rationale: A comprehensive approach supports physical, emotional, and spiritual needs.
A client scores 6/6 on Katz ADL but 4/8 on Lawton IADL. What should the nurse recommend?
A. Long-term care
B. Full independence
C. Home assistance for complex tasks
D. Skilled nursing placement
C – Home assistance for complex tasks
Rationale: IADL deficits indicate the need for supervision with higher-leve
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 asks about transportation and local senior meal programs. What is being assessed?
A. Social support
B. Contexts of care
C. ADL performance
D. Cultural background
B – Contexts of care
Rationale: Contexts of care include home, community, and resource access.