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Practice Question

The nurse is performing a functional assessment of an older adult to determine safety in the home. Which musculoskeletal assessment is most important for the nurse to include?

Answer Choices:

Correct Answer:

Observe gait while walking.

Rationale:

🟦 When assessing an older adult’s safety in the home, the most important musculoskeletal assessment is to observe gait while walking, because gait abnormalities significantly increase the risk for falls, which are one of the leading causes of morbidity and mortality in older adults.

🟦 Gait observation allows the nurse to evaluate balance, coordination, stride length, weight-bearing ability, and need for assistive devices, all of which determine how safely the client can move around their home.

🟦 Early identification of gait instability helps guide interventions such as home modifications, physical therapy, fall-prevention education, and assistive equipment.

🟦 This assessment directly reflects functional mobility and independence—key factors in an elderly person’s ability to safely navigate their living environment.

🟦 Therefore, observing the client’s gait is the most crucial musculoskeletal assessment for determining home safety.

Incorrect Options Explained

Palpate for joint nodules

— Useful for diagnosing arthritis, but joint nodules do not directly determine home safety or fall risk.

Compare shoulder symmetry

— Identifies deformities, but does not assess functional mobility or predict hazards in the home.

Assess for spinal scoliosis

— Important for posture evaluation, but scoliosis is not a major fall predictor in older adults and does not directly impact home safety.

Want to practice more questions like this?

This question is from Fall 2025-BSN -246 RN Health Assessment which contains 59 questions.

More Questions from This Exam
 In assessing a client's heart sounds, the nurse hears an S₁ and S2 after placing the diaphragm of the stethoscope at the second intercostal space just to the right of the sternum while the client is supine in bed. Which action should the nurse take next?

Answer Choices:

A. Document the presence of normal heart sounds in the client's chart.
B. Assist the client to turn to a left side-lying position in the bed.
C. Move the diaphragm of the stethoscope to the left of the sternum.
D. Inch the stethoscope down the right side of the sternum.
 The nurse is performing a mental status examination and asks an adult client to interpret a familiar proverb. When the client is unable to interpret the proverb, the nurse repeats the instructions and the client is still unable to accurately interpret it. Which action should the nurse implement?

Answer Choices:

A. Explain the meaning of the proverb and ask the client to repeat it.
B. Provide a different proverb for the client to interpret.
C. Reschedule the exam for another time.
D. Document client's difficulty with abstract reasoning.
 The nurse examines a client who is concerned about the amount of menstrual flow she is having. Which finding indicates an abnormality related to the client's current menstruation?

Answer Choices:

A. Cramping associated with the amount of flow.
B. Blood clots sized at 0.5 cm (0.2 in) with menstrual flow.
C. Blood saturation of one pad an hour.
D. An odorless, red menstrual blood flow.
 A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?

Answer Choices:

A. Extend arms up to 180 degrees beside the ears.
B. Alternate both index fingers to touch the tip of nose accurately.
C. Extend arms straight out and hold without drifting.
D. Hold arms up at 90 degrees while arms are pushed downward.
From Exam
Fall 2025-BSN -246 RN Health Assessment

59 Questions

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Question Details
  • Category: RN Nursing Exam(s)
  • Subcategory: ATI Exam(s)
  • Domain: Health Assessment
  • Answer Choices: 4
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