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
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