Study guide
3.1 Functional Assessment
ANCC Family Nurse Practitioner FNP-BC
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1 Introduction & Exam Overview
1.1 Current Exam Facts 1.2 Eligibility, Application, and Test Day 1.3 Blueprint Weights, TCO Dates, and Study Strategy
2 Assessment Foundations
2.1 Population Health Promotion and Screening 2.2 Comprehensive History and Physical 2.3 Focused History and Physical 2.4 Age-Specific Screening Schedules
3 Function, Risk, and Lifespan Assessment
3.1 Functional Assessment 3.2 Risk Assessment and Social Determinants 3.3 Pediatric Developmental Assessment 3.4 Adolescent, Adult, and Geriatric Assessment
4 Diagnosis Foundations
4.1 Pathogenesis and Pathophysiology 4.2 Diagnostic Test and Procedure Selection 4.3 Interpreting Labs and Imaging 4.4 Normal vs Abnormal Physiologic Change
5 Differential Diagnosis
5.1 Formulating Differential Diagnoses 5.2 Red Flags and Emergency Identification 5.3 Diagnostic Reasoning Traps
6 Prevention and Anticipatory Guidance
6.1 Primary, Secondary, and Tertiary Prevention 6.2 Pediatric and Adolescent Anticipatory Guidance 6.3 Adult and Geriatric Anticipatory Guidance 6.4 Immunization Planning Across the Lifespan
7 Guidelines, Culture, and Evidence
7.1 Crisis, Safety, and End-of-Life Planning 7.2 Clinical Guidelines and Standards of Care 7.3 Culturally and Ethnically Sensitive Practice 7.4 Evidence-Based Research Appraisal
8 Care Plans and Shared Decisions
8.1 Shared Decision-Making 8.2 Multimorbidity and Prioritization 8.3 Referral, Comanagement, and Transitions
9 Pharmacotherapeutics
9.1 Pharmacokinetics, Pharmacodynamics, and Pharmacogenetics 9.2 Interactions, Contraindications, and Monitoring 9.3 Special-Population Prescribing 9.4 High-Alert Medications and Analgesic Safety
10 Cardiovascular Primary Care
10.1 Cardiovascular Diagnosis 10.2 Cardiovascular Pharmacotherapy 10.3 Nonpharmacologic Cardiovascular Management 10.4 Lifespan Cardiovascular Issues
11 Respiratory Primary Care
11.1 Respiratory Diagnosis 11.2 Respiratory Pharmacotherapy 11.3 Lifespan Respiratory Care
12 Endocrine and Metabolic Primary Care
12.1 Diabetes Diagnosis and Monitoring 12.2 Diabetes Pharmacotherapy 12.3 Thyroid and Other Endocrine Disorders 12.4 Obesity and Metabolic Disease
13 Gastrointestinal Primary Care
13.1 Gastrointestinal Diagnosis 13.2 GI Pharmacotherapy and Nutrition 13.3 Lifespan Gastrointestinal Care
14 GU, Renal, and Reproductive Primary Care
14.1 GU and Renal Diagnosis and Management 14.2 Women's Reproductive Health 14.3 Pregnancy and Postpartum Primary Care 14.4 Men's Health and Sexual Function
15 HEENT, Skin, and Musculoskeletal
15.1 HEENT Diagnosis and Management 15.2 Integumentary Diagnosis and Management 15.3 Musculoskeletal Diagnosis 15.4 MSK Procedures and Nonpharmacologic Care
16 Neuro, Psych, Heme, Immune, and Infection
16.1 Neurological Diagnosis and Management 16.2 Psychiatric Diagnosis and Substance Use 16.3 Hematopoietic and Immune Disorders 16.4 Common Infections and Anti-Infectives
17 Clinical Delivery Skills
17.1 Office Procedures and Nonpharmacologic Treatment 17.2 Patient-Specific Education 17.3 Therapeutic Communication 17.4 Comprehensive Documentation
18 Professional Practice
18.1 Legal and Ethical Implications 18.2 Health IT, EHR, and AI Ethics 18.3 Regulatory Guidelines: Reportable Disease and Abuse 18.4 APRN Scope, Standards, and FNP Role
19 Outcome Evaluation
19.1 Ethical and Legal Evaluation Issues 19.2 Pharmacotherapeutic Outcome Monitoring 19.3 Nonpharmacologic Outcome Monitoring 19.4 Clinical Data, PROs, and Treatment Efficacy
20 Follow-Up, Systems, and Exam Strategy
20.1 Follow-Up Intervals and Surveillance 20.2 Treatment Adjustment and Deprescribing 20.3 Resource Management and Care Coordination 20.4 Exam-Day Strategy and TCO Review
3.1 Functional Assessment
Key Takeaways Explain This Topic AI
Function is what the patient can safely do this week — ADLs (Katz), IADLs (Lawton), gait, senses, cognition, mood, development, school, and caregiver capacity — not the diagnosis on the problem list.
IADL loss (money, medicines, shopping, driving) usually precedes ADL loss and is often the first office clue to cognitive decline.
A Mini-Cog of 0–2, TUG of 12 seconds or longer, or new caregiver strain is a positive screen that opens a workup and a safety plan; it is not a dementia, fall, or placement diagnosis by itself.
Frail elderly is a physiologic state (loss of reserve: Fried phenotype or clinical frailty), not a synonym for older adult.
When function changes — driving, living situation, work, or sports clearance — the plan changes even if the ICD-10 code does not.
Last updated: August 2026
Quick Answer: Function is what the patient can safely do, not the diagnosis on the problem list. Screen ADLs (Katz) and IADLs (Lawton), gait and fall risk (TUG, 30-second chair stand, fall history), senses (hearing and vision), cognition and mood (Mini-Cog, PHQ-2/9, GAD-7; MoCA or AD-8 when indicated), development and school performance in children, and caregiver strain. A positive screen changes driving, living situation, work, or sports clearance even when the ICD-10 code does not.
ANCC Domain I lists functional assessment as a distinct skill: cognitive, developmental, physical capacity, and family/caregiver roles. The exam is testing whether you treat function as data that revises risk and disposition, not as a courtesy paragraph after the 'real' physical.
ADLs versus IADLs — Katz and Lawton
Activities of daily living (ADLs) are the self-care tasks required to live inside the home without hands-on help. The Katz Index scores six: bathing, dressing, toileting, transferring, continence, and feeding. Dependence in even one ADL — especially transferring or toileting — raises fall, infection, pressure-injury, and placement risk.
Instrumental ADLs (IADLs) are the community-living tasks that keep an adult independent. The Lawton IADL Scale covers telephone use, shopping, food preparation, housekeeping, laundry, transportation, medication management, and finances. IADL loss usually precedes ADL loss. A patient who still bathes and dresses independently but can no longer manage refills or the checkbook is already functionally impaired.
Exam trap: the word 'independent' in last year's history is not a functional assessment. Ask a concrete week. Who shopped? Who set up the pillbox? Who drove you here? Who paid the rent? Collateral from a partner or adult child is part of the assessment, not gossip. Patients with early executive dysfunction often give a polished, overconfident self-report.
Domain What it measures Typical tool Why it matters
Basic self-care Bathing, dressing, toilet, transfer, continence, feeding Katz ADL Home-care hours, placement, infection and fall risk
Community living Phone, shop, cook, clean, laundry, travel, meds, money Lawton IADL Earlier marker of cognitive or medical decline
Mobility Gait, strength, endurance TUG, 30-second chair stand, gait speed Fall risk, frailty, discharge safety
Cognition Memory, executive function Mini-Cog; MoCA when indicated; AD-8 informant Driving, medicines, consent, living situation
Mood and anxiety Depression, anxiety burden PHQ-2 then PHQ-9; GAD-7 Function, suicide risk, treatment response
Development Motor, language, social, problem-solving Surveillance plus ASQ, M-CHAT-R/F, Vanderbilt Early intervention versus watchful waiting
Caregiver Burden, role strain Zarit conceptually; unstructured role questions Patient safety depends on the caregiver remaining able
Physical capacity: gait, strength, and falls
Do not wait for a fracture to ask about mobility.
Timed Up and Go (TUG): rise from a chair, walk 3 meters, turn, return, and sit. CDC STEADI treats 12 seconds or longer in community-dwelling older adults as a positive fall-risk screen. Watch the quality. Hesitation, path deviation, pushing off with the arms, or a near-loss of balance is data even if the stopwatch reads 11 seconds.
30-second chair stand: arms crossed, stand and sit as many times as possible in 30 seconds. A count below the CDC STEADI age- and sex-specific norm flags lower-extremity weakness and fall risk. It is a better strength screen than 'any trouble with stairs?'
Gait speed under about 0.8 meters per second is associated with frailty, hospitalization, and mortality. You do not need a gait lab — mark 4 meters in the hallway.
Fall history is part of the functional exam. Ask about falls in the past year, near-falls, fear of falling that has already restricted activity, injuries, and whether the last fall was a clear trip or unexplained. One unexplained fall plus a gait abnormality is enough to open a multifactorial workup: orthostatic vitals, medicines (especially anticholinergics, benzodiazepines, opioids, and antihypertensives), vision, feet and footwear, home hazards, and cognition.
Hearing and vision as function
Uncorrected hearing and vision loss impersonate dementia, depression, nonadherence, and a 'poor historian.' A whispered-voice or single-question hearing screen, otoscopy, and asking about the last refraction are functional tools. A patient who stopped driving at night or no longer attends services because of hearing is already restricted. Treat sensory loss as a reversible contributor to IADL decline before you label major neurocognitive disorder.
Cognition, mood, and informant screens
Mini-Cog (3-item recall plus clock draw) is a brief primary-care screen. Scores of 0–2 are a positive screen and require a fuller evaluation — not an automatic dementia diagnosis. Do not start a cholinesterase inhibitor from a Mini-Cog alone.
MoCA is more sensitive for mild cognitive impairment. A commonly cited cutoff is below 26 out of 30 , education-adjusted. Use it when the Mini-Cog is positive, the history is subtle (executive or language complaints with intact recall), or family reports a change the patient denies. Administration requires training; do not eyeball a homemade version and call it a MoCA.
AD-8 is an 8-item informant interview. It catches decline the patient minimizes. A positive informant screen with a reassuring patient interview is still a positive cognitive assessment.
PHQ-2 (anhedonia plus depressed mood) is the depression gate. A positive PHQ-2 leads to PHQ-9 , review of the suicide item, and a function question: work, school, parenting, sleep, appetite. GAD-7 screens anxiety that commonly drives school avoidance, somatization, and caregiver collapse. Mood scores are functional data. A PHQ-9 of 18 with passive death wishes changes the same-day plan even if the stated chief complaint was fatigue.
Developmental surveillance, structured tools, and school function
In infants, preschoolers, and school-age children, function is development plus school participation.
Surveillance happens at every well visit: parental concern, milestone review, observation in the room, and risk factors (prematurity, hearing loss, lead, early adversity). Surveillance is not optional small talk.
Structured tools are added at recommended ages or whenever surveillance is concerning:
ASQ-3 / ASQ:SE — parent-completed developmental and social-emotional screens across infancy and preschool.
M-CHAT-R/F — autism screen at 18 and 24 months (usable 16–30 months), with the follow-up interview for medium-risk scores.
Vanderbilt ADHD (or a similar validated scale) — parent and teacher ratings. A 10-minute office impression of a squirmy 8-year-old is not an ADHD assessment.
School function belongs in the history: grades, IEP or 504, suspensions, attendance, bullying, and whether homework takes three hours because of attention, reading, or anxiety. A child who meets motor milestones but is failing third-grade reading is functionally impaired.
Caregiver burden and family role strain
The identified patient may be stable only because a spouse, adult child, or grandparent is absorbing the work. The Zarit Burden Interview (full or short form) conceptually measures guilt, time, health, and financial strain. You do not have to administer the full scale on an exam vignette — you do have to ask who provides care, how many hours, whether the caregiver is missing work or sleep, and whether they are considering placement.
Role strain is bidirectional. A parent of a medically complex preschooler, a teen parenting a sibling, or a middle-aged adult sandwiched between a toddler and a parent with dementia all have functional assessments of their own. Caregiver collapse is a disposition-changing finding.
When function — not diagnosis — changes the plan
The same diagnosis produces different plans when function differs.
Driving: unexplained syncope, a markedly prolonged TUG, a positive Mini-Cog plus family reports of near-misses, visual acuity below the state standard, or alcohol use with a prior impaired-driving event. Counsel to stop driving when safety is in doubt and know your state's reporting rules.
Living situation: new ADL dependence without a safe caregiver is a same-day safety problem, not a 'follow up in 3 months' note.
Work: a warehouse worker with recurrent back pain who can no longer lift is a functional, occupational, and forms problem, not only a musculoskeletal diagnosis.
Sports clearance: concussion with persistent balance or cognitive symptoms, cardiac symptoms on the AHA 14-element history, or a single kidney or single eye in a collision sport changes clearance even if the resting exam is normal.
Frail elderly versus merely older adult
Older adult is an age band. Frail elderly is a physiologic state: decreased reserve and increased vulnerability to stressors. The Fried phenotype counts unintentional weight loss, self-reported exhaustion, weak grip, slow gait, and low activity. Three or more features = frail ; one or two = prefrail. The Clinical Frailty Scale (Rockwood) is a 1–9 judgment from very fit to terminally ill that already incorporates function.
An 82-year-old who walks a mile, manages taxes, and takes two medicines is an older adult. A 74-year-old on 12 medicines, with two unexplained falls, a Mini-Cog of 1, and a daughter who now does all the cooking is frail. The second patient has a different pretest probability for delirium, adverse drug events, and failed outpatient treatment. Chronologic age alone does not make the distinction.
Tool → age → positive next step
Tool Typical age Positive finding Next step
ASQ-3 1 month–5.5 years Domain in the black zone or strong parental concern Recheck soon or refer Early Intervention / developmental pediatrics
M-CHAT-R/F 18 and 24 months High risk, or medium risk after the follow-up interview Refer autism-specific evaluation, audiology, and EI; do not watch until age 3
Vanderbilt School-age Impairment at home and school Assess comorbidities; do not treat from office fidgeting alone
Mini-Cog Older adult Score 0–2 Fuller cognitive testing; medicine and safety review; driving and IADL check
MoCA Older adult or high-risk adult Below 26 (education-adjusted) Work up reversible causes; consider specialty; do not diagnose from the score alone
PHQ-2 then PHQ-9 Adolescent through older adult PHQ-2 of 3 or more, PHQ-9 of 10 or more, or any suicidal ideation Safety plan; treat or refer; recheck function
- GAD-7 Adolescent through adult 10 or more (moderate) Function review; treat or refer
- AD-8 Older adult (informant) Two or more items Cognitive workup even if the patient denies change
- TUG Older or frail adult 12 seconds or longer, or unsafe quality STEADI-style multifactorial fall assessment
30-second chair stand Older or frail adult Below age- and sex-specific norm Strength program, physical therapy, fall precautions
Katz / Lawton Adult through frail elderly New dependence Home safety, services, caregiver assessment
Zarit (conceptually) Caregiver of any age High strain or 'I cannot continue' Respite, social work, treat caregiver depression
Vignette
A 79-year-old woman is 'here for blood pressure.' She lives alone, still drives, and says she is fine. Her daughter, who scheduled the visit, reports two grocery-store near-falls, unpaid bills, and a burned pot last month. TUG is 16 seconds with a path deviation. Mini-Cog is 2 (recalls one of three words; clock numbers are clustered on one side). PHQ-2 is 3. She takes diphenhydramine for sleep.
The assessment is not 'hypertension, stable.' It is IADL loss, positive cognitive and fall screens, possible depression, and a high-risk medicine in a woman who is still driving. Today's plan must address safety (driving, home, medicines), depression, and a scheduled cognitive workup — not only a refill.