The home care nurse assessed a client with a history of dementia ...

[lunatika]

The home care nurse assessed a client with a history of dementia who had a herniorrhaphy at an ambulatory surgical center the previous day. The client lives in a senior retirement community and has no close family.
 
  The nurse assesses mild dysphasia. The client cannot remember why he has a bandage. He thinks he is in the army and that it is 1950. Appropriate planning for the client should include:
  1. Arranging an appointment at a geriatric assessment program; OT referral for swallowing therapy; teaching to manage public transportation
  2. Attending English class to improve speech; transferring finances to a conservator; employing an aide to help with medications
  3. Arranging Meals on Wheels, attending speech therapy; relocation to a skilled nursing facility if no improvement in 1 month
  4. Assessing diet and meal preparation; assessing environment for safety problems; referral to a dementia program

Question 2

A 63-year-old female has been admitted to the hospital for cholecystitis. She is accompanied by her sister, who provides all the assessment data while the client sits and stares somewhat vacant-ly.
 
  You determine that the client is single, lives alone, and lost her job as a secretary last year when she was unable to learn a new computer system. The sister states she has recently had to manage the client's shopping, meal preparation, and finances. Which of the following are appropriate nursing diagnoses?
  1. Pain, self-care deficits, situational low self-esteem
  2. Anxiety, self-care deficits, disturbed thought processes
  3. Impaired home maintenance, disturbed thought process, impaired verbal commu-nication
  4. Disturbed body image, anxiety, pain

[1_Step_At_ATime]

Answer to Question 1

ANS: 4
Further assessment is appropriate before making changes in living environment. Enrolling in a dementia program will provide stimulation and help the client maintain intellectual skills. 1. None of these interventions is warranted. 2. English classes will not improve speech. The other plans might have relevance, however. 3. The client may be able to manage food preparation, even though he is disoriented at present.

Answer to Question 2

ANS: 3
The scenario documents client inability to manage ADLs, inability to learn a new computer sys-tem, and reliance on the sister to communicate for her. Data do not support the diagnoses listed in the other options.

[lunatika]

Excellent

[atrochim]

TYSM