An 85-year-old client with dementia has a nursing diagnosis of Self-care deficit: bathing, hy-giene
She lives at home and has not bathed for a month. Her 67-year-old daughter states that she thinks her mother may have forgotten how to take a shower. An appropriate outcome would be that the client will:
1. Bathe daily with reminders
2. Bathe twice weekly with assistance
3. Allow the nurse to totally manage hygiene
4. Remain free of skin diseases/lesions
ANS: 2
Bathing twice weekly would be a realistic goal. Assistance should be provided, both to prevent falls and to regulate shower temperature. 1. The elderly are advised not to bathe daily because it is too drying to their skin. 3. This may not be necessary; the client should retain as much autono-my as possible. 4. This goal is not directly related to the nursing diagnosis.
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Pyridoxine is ordered for a client. The nurse understands that which of the following will be given?
1. Niacin 2. Riboflavin 3. Thiamin 4. Vitamin B6
Which clients will require a rapid assessment? Select all that apply.
A. The client was admitted to the hospital yesterday and is being treated with intravenous antibiotics for pneumonia. B. The nurse is new to the unit and is planning care for the four clients that have been assigned to the nurse. C. The client begins to complain of difficulty breathing. The client's oxygen saturation level has decreased from 93% on room air this morning to 87%. D. The client had an open appendectomy 2 days ago and is preparing to be discharged today. E. The client has just been received from the Post Anesthesia Care Unit.
The nurse is administering testosterone to a client with breast cancer. The nurse recognizes that this therapy is part of the client's treatment plan because:
1. testosterone has a high affinity for rapidly dividing cancer cells. 2. testosterone decreases the inflammation associated with rapid tumor growth. 3. testosterone replicates the action of antineoplastic drugs without nausea. 4. testosterone blocks the growth of estrogen-sensitive cancers.