While bathing an elderly client who has limited abilities for ...

[Lisaclaire]

While bathing an elderly client who has limited abilities for self-care, the nurse notices several patches of dry skin on the client's heels, elbows, and coccyx. The nurse cleans and dries all the areas well and applies a moisturizing lotion.
 
  The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this client's skin is to:
  1. Revise the client's care plan to show the need for the application of moisturizing lotion
  2. Assume personal responsibility to apply the moisturizing lotion daily to the cli-ent's skin
  3. Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin
  4. Inform the staff that the client's skin is showing signs of breakdown and mois-turizing lotion needs to be applied daily

Question 2

The nurse tests the function of the client's cranial nerves during the neurological component of the physical examination. In testing cranial nerve III, the nurse verifies the client's ability to:
 
  1. Smile and frown
  2. Read printed material
  3. Identify sweet and sour tastes
  4. React to light with changes in pupil size

[ngr69]

Answer to Question 1

ANS: 1
The nurse revises the written care plan so that other nurses and nursing assistive personnel know the type of skin care to provide. The other options are less likely to convey the information effec-tively.

Answer to Question 2

ANS: 4
In testing cranial nerve III (oculomotor), the nurse determines the client's ability to react to light with changes in pupil size. Testing accommodation will also assess cranial nerve III. In testing cranial nerve VII (facial), the nurse determines the client's ability to smile and frown. In testing cranial nerve II (optic), the nurse determines the client's ability to read printed material. In testing cranial nerve IX (glossopharyngeal), the nurse determines the client's ability to identify sweet and sour tastes.