Chapter 31: Functional Assessment of the Older Adult

Jarvis: Physical Examination & Health Assessment, 3rd Canadian edition

MULTIPLE CHOICE

1. The nurse is assessing an older adult’s functional ability. The nurse will need to determine
the patient’s:
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
ANS: D
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.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance

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

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

3. The nurse needs to assess a patient’s ability to perform activities of daily living (ADLs) and
should choose which tool for this assessment?
a. Direct Assessment of Functional Abilities (DAFA)
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)
ANS: C
The Barthel Index is used to assess ADLs. The other options are used to measure IADLs.

DIF: Cognitive Level: Understanding (Comprehension)

 MSC: Client Needs: Health Promotion and Maintenance

4. 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.
ANS: B
The Lawton IADL instrument is designed as a self-report measure of performance rather
than ability. Direct testing, such as demonstrating the ability to prepare food while a hospital
inpatient, is often not feasible. 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.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

5. The nurse is assessing an older adult’s advanced activities of daily living (AADLs), which
would include:
a. Recreational activities
b. Meal preparation
c. Balancing the chequebook
d. Self-grooming activities
ANS: A
AADLs are activities that an older adult performs, for example, occupational and
recreational activities. Self-grooming activities are basic ADLs; meal preparation and
balancing the chequebook are considered IADLs.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance

6. When using the various instruments to assess an older person’s 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
ANS: B
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.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance
7. 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?
a. Timed Up and Go Test
b. Performance Activities of Daily Living test
c. Physical Performance Test
d. Tinetti Gait and Balance Evaluation
ANS: A
The Timed Up and Go Test 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. This instrument has been shown to predict a
person’s ability to go safely outside alone. The Performance Activities of Daily Living test
has a trained observer actually observing as a patient performs various ADLs. The Physical
Performance Test assesses upper body fine motor and coarse motor activities, balance,
mobility, coordination, and endurance. The Tinetti Gait and Balance Evaluation assesses gait
and balance and provides information about fall risk. In a review of 17 functional balance
tests, Langley and Mackintosh recommended the Timed Up and Go Test as valid and
reliable for the older adult population.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance

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?
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
ANS: D
Informal support includes family and long-time close friends and is usually provided free of
charge. Formal supports include programs, such as social welfare and other social services,
and health care delivery agencies, such as home health care.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity

9. 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:
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
ANS: D
 The health and well-being of the older adult and caregiver are closely linked. 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 stress was greatest when caregiving for a spouse,
with almost half (47.2%) reporting distress. One formal screening tool is the Modified
Caregiver Strain Index (Figure 31-5), which is used to identify caregivers of any age who
need a more comprehensive assessment. CARENET has excellent resources for people
caring for individuals at the end of life. The Duke Social Support and Stress Scale measures
a patient’s perceptions of support and stress in family and nonfamily relationships.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity

10. 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?
a. Geriatric Depression Scale, short form
b. Rapid Disability Rating Scale-2
c. Mini-Cog
d. Timed Up and Go Test
ANS: C
For nurses in various settings, cognitive assessments provide continuing comparisons to the
individual’s baseline to detect any acute changes in mental status. The Mini-Cog is a mental
status test that assesses immediate and delayed recall and visuospatial abilities. The
Geriatric Depression Scale, short form, assesses for depression and changes in the level of
depression, not mental status. The Rapid Disability Rating Scale-2 measures what the
person can actually do versus what he or she could do, but not mental status. The Timed Up
and Go Test assesses functional mobility, not mental status.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity

11. 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?
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.”
ANS: B
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.

DIF: Cognitive Level: Analyzing (Analysis)

 MSC: Client Needs: Safe and Effective Care Environment: Safety and Infection Control

12. When beginning to assess a person’s spirituality, which question by the nurse would be most
appropriate?
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?”
ANS: B
Open-ended questions provide a foundation for future discussions. The other responses are
easily answered by one-word replies and are closed questions.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Psychosocial Integrity

13. 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?
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.
ANS: C
If the older adult is experiencing pain or discomfort, then the information gathered through
the assessments will be incomplete. 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.

DIF: Cognitive Level: Analyzing (Analysis)

MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

14. The nurse is working with the older adult population and recognizes that polypharmacy can
increase the risk for the older adult for:
a. Increased sexuality
b. Reduction of falls
c. Decrease in functional ability
d. Improved cognition
ANS: C
Polypharmacy is the prescription and use of multiple medications (usually five or more) to
deal with concomitant multiple diseases and can lead to adverse drug events, such as
medication interactions, decreased functional status, cognitive impairment, and falls.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Physiologic Integrity: Basic Care and Comfort

15. 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:
 a. Assess for physical and cognitive changes
b. Determine potential elder abuse
c. Measure physical function
d. Evaluate support and stress
ANS: B
• The mnemonic (STOP HARM) can help detect, diagnose, and manage elder abuse:
o Screen for abuse in all older adult patients
o Think about risk factors
o Ominous danger signs present?
o Physical findings
o History
o Address issue of elder abuse
o Report to adult protective services
o Manage with prevention and risk factor modification
• The Physical, Intellectual, Emotional, Capabilities, Environment and Social
(PIECES) program was developed for all health care providers to enhance
understanding of and care for patients with complex physical and cognitive/mental
health needs and behavioural changes.
• The Katz Index of ADL is based on the concept of physical disability and was
intended to measure physical function in older adults and chronically ill patients.
• The Duke Social Support and Stress Scale is a measure of a patient’s perceptions of
support and stress in family and nonfamily relationships.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity

MULTIPLE RESPONSE

1. 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 the chequebook
d. Walking
e. Toileting
f. Grocery shopping
ANS: B, C, F
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.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance
2. 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.)
a. Cognition
b. Physical performance
c. Weight-loss strategies
d. Social networks
e. Functional ability
f. Artistic ability
ANS: A, B, D, E
A comprehensive assessment incorporates both the physical examination and assessments of
an individuals’ mental, functional, social, and economic status; pain; and the physical
environment for safety concerns.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity

3. 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.)
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
ANS: A, C, E
To be eligible for medical assistance in dying, an individual must be eligible for government
health care coverage (not a visitor to Canada), be at least 18 years old, have a grievous and
irremediable medical condition (be actively dying), make a voluntary request for medical
assistance in dying, and be able to give informed consent.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Psychosocial Integrity