An older adult client had hip replacement surgery 1 day ago, and the nurse thinks that the client is also demonstrating dementia. Which client assessment does the nurse use to determine whether this client is experiencing pain?

Choice A reason: Controlling fluid balance is the most important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as fluid overload is the main cause of HF worsening and hospital admission. Fluid balance can be controlled by monitoring weight, intake and output, edema, and lung sounds, and by administering diuretics, restricting sodium and fluid intake, and elevating the legs.

Choice B reason: Controlling blood pressure is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as hypertension is a risk factor and a complication of HF. However, it is not the most important goal, as blood pressure may not always reflect the fluid status or the severity of HF. Blood pressure can be controlled by administering antihypertensive medications, such as angiotensin-converting enzyme inhibitors, beta-blockers, or calcium channel blockers, and by encouraging lifestyle modifications, such as smoking cessation, weight management, and stress reduction.

Choice C reason: Preventing deconditioning is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as deconditioning is a common problem in HF patients due to reduced physical activity, fatigue, and muscle wasting. However, it is not the most important goal, as deconditioning may not directly affect the fluid balance or the cardiac function. Deconditioning can be prevented by providing exercise training, such as aerobic, resistance, or interval training, and by promoting self-care and adherence to the treatment regimen.

Choice D reason: Maintaining client safety is an important goal in the nursing plan of care to decrease the frequency of hospitalizations for acute exacerbations of HF in older adults, as HF patients are at risk of falls, injuries, infections, or adverse drug reactions. However, it is not the most important goal, as client safety may not specifically address the fluid balance or the cardiac function. Client safety can be maintained by providing a safe environment, such as removing clutter, providing adequate lighting, and using assistive devices, and by preventing complications, such as monitoring for signs of infection, bleeding, or electrolyte imbalance, and by educating the client and the family about the medications, the signs and symptoms of HF worsening, and the emergency measures.

Choice A: Use an antifungal cleanser daily. This is not a correct answer. Antifungal cleansers are not recommended for treating fungal infections, as they can irritate the skin and disrupt the natural balance of the skin flora¹. Antifungal cleansers may also reduce the effectiveness of other antifungal medications².

Choice B: Eliminate the conditions that created the problem. This is a correct answer. Fungal infections are often caused by factors that create a favorable environment for fungi to grow, such as moisture, warmth, poor hygiene, or weakened immunity³. Eliminating these conditions can help prevent or treat fungal infections by reducing the fungal load and restoring the skin barrier.

Choice C: Thoroughly clean and dry skin daily. This is also a correct answer. Cleaning and drying the skin daily can help remove dirt, sweat, and dead skin cells that can harbor fungi and cause infections. Drying the skin well, especially in the folds and creases, can also prevent moisture buildup that can promote fungal growth.

Choice D: Apply 4x4 dressings to the affected site.This is not a correct answer. Applying dressings to the affected site can trap moisture and heat, which can worsen fungal infections. Dressings may also interfere with the absorption of topical antifungal medications. Dressings are only indicated for fungal infections that cause open wounds or ulcers, and they should be changed frequently and kept clean and dry..