The nurse is assessing a 78-year-old client who lives alone in his own home. To assess the client's instrumental activities of daily living, which question would be most appropriate to ask?

Correct Answer: D

Rationale: The correct answer is D because assessing the client's ability to go to the store and buy groceries directly evaluates their instrumental activities of daily living (IADLs), which are crucial for independent living. This question helps determine the client's mobility, cognitive function, and ability to manage finances and nutrition. Choices A and B focus more on basic activities of daily living (ADLs) related to personal hygiene and clothing changes. Choice C is related to cooking meals, which is also an IADL but may not provide as comprehensive information about the client's overall independence compared to the ability to shop for groceries.

Correct Answer: C

Rationale: The correct answer is C: "We've installed locks on all the outside doors." This statement shows an understanding of the need to prevent the patient with dementia from wandering off and getting lost or injured. Installing locks on outside doors helps to ensure the patient's safety by limiting their ability to leave the house unsupervised. This measure is crucial in providing a secure environment for someone with dementia. Explanation: A: The statement about the local police knowing the patient has wandered off before does not address the immediate need to prevent wandering and ensure safety. B: Keeping the noise level low in the house may be helpful for a patient with dementia, but it does not directly address the safety concern of wandering. D: Attaching the telephone number to the patient's shirt pocket is a good safety measure, but it does not address the primary concern of preventing the patient from wandering off.

Correct Answer: D

Rationale: The correct answer is D: transition of care. Transition of care refers to clients moving between treatment settings, ensuring continuity and coordination of care. Rehospitalization (A) specifically refers to clients being admitted back to the hospital. Adverse event (B) refers to harm resulting from medical care. Readmission (C) is similar to rehospitalization, specifically indicating clients being admitted back to a hospital after a previous discharge. Transition of care (D) is the most appropriate term as it encompasses the movement of clients between various healthcare settings beyond just hospitals.

Correct Answer: B

Rationale: The correct answer is B because it highlights the importance of checking for congruence between verbal and nonverbal communication to validate responses. This demonstrates an understanding that nonverbal cues can provide additional insights into a patient's true feelings or thoughts. Choice A is incorrect as it simply states a general observation without emphasizing the significance of nonverbal cues. Choice C is incorrect because assuming a patient's emotions based solely on body posture is not accurate or reliable. Choice D is incorrect as it undervalues the importance of nonverbal communication in understanding the complete message being conveyed.

Correct Answer: A

Rationale: The correct answer is A: Disturbed Body Image. This is the priority nursing diagnosis for a client with body dysmorphic disorder because it directly addresses the client's preoccupation and distress related to perceived flaws in appearance. By addressing the disturbed body image, the nurse can help the client work through these feelings and improve self-perception. Choice B: Ineffective Coping may be relevant but addressing the underlying body image distortion is crucial. Choice C: Low Self-Esteem is a common issue with body dysmorphic disorder but improving body image perception is more specific. Choice D: Risk for Other-Directed Violence is not directly related to body dysmorphic disorder symptoms. In summary, addressing the core issue of distorted body image is the priority in caring for a client with body dysmorphic disorder.