A nurse is assessing a patient's ability to perform activities of daily living. Which action would the nurse have the client perform as part of this assessment process?

 

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Correct

- Put both hands together behind the head

- Stand on one foot

- Close the eyes and hold the arms out to the sides

- Ask the patient to interact with family members

Rationale

"Put both hands together behind the head" is correct. A nurse can assess a patient's abilities to perform activities of daily living (ADLs) by performing a simple assessment. This helps to inform the nurse about how much care the patient needs and what she can do herself. Asking the client to perform small tasks, such as clasping the hands behind the head or pulling against a small amount of resistance can help the nurse to discern the patient's functional abilities. Simply observing the patient performing simple tasks in the room is an additional source of information regarding the patient's abilities.

"Stand on one foot" is incorrect because this is not a necessary action to accomplish daily living tasks and is potentially dangerous.

"Close the eyes and hold the arms out to the sides" is incorrect because this describes a neurological test to detect poor balance. Assessing activities of daily living is not whether a patient has poor balance, but rather how the patient manages the abilities she has to complete her daily tasks.

"Ask the patient to interact with family members" is incorrect because this is not related to a patient's ability to individually accomplish her ADLs.

References:
Elsawy, B., & Higgins, K. E. (2011, January 01). The Geriatric Assessment. Retrieved from https://www.aafp.org/afp/2011/0101/p48.html

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