Practice Quiz

CMSRN Medical-Surgical Nursing

Category - Endocrine

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Mrs. Keller is an elderly client with dry flaky skin and activity intolerance secondary to myxedema. She was admitted to the progressive care unit to improve her activity intolerance and gain independence in self-care. For hygiene care the nursing order is two total baths per week on Saturday and Wednesday, with partial baths on the remaining days of the week. Which of the following would be the desired outcome of this intervention?
  1. Client is able to sleep through the night and stay awake most of the day.
  2. Gradual increase in ambulation ability over the first month.
  3. Increased energy by the end of the first week of paced rest and activity.
  4. Intact elastic moist warm skin by the end of first week.
Explanation
Answer - D - Intact elastic moist warm skin by the end of first week. Daily total baths remove the protective sebum from the skin, placing the client at risk for altered skin integrity. Since the client’s level of participation in the bath or other self-care activity is not presented, the other 3 choices are inappropriate. In addition, Choices B and C are not specific and measurable enough to meet criteria for an outcome statement.
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