The nurse is conducting a physical assessment for a client with a ...

[lb_gilbert]

The nurse is conducting a physical assessment for a client with a compromised immune system. Which actions by the nurse are appropriate?
 
  Select all that apply.
  A) Assessing general appearance
  B) Recommending increased fluid intake
  C) Inspecting the mucous membranes of the nose and mouth for color and condition
  D) Palpating the cervical lymph nodes for evidence of lymphadenopathy or tenderness
  E) Checking joint range of motion (ROM), including that of the spine

Question 2

The nurse is caring for a client who is being discharged following an appendectomy. Which instruction is the most important for the nurse to teach this client regarding wound healing?
 
  A) Thoroughly irrigate the wound with hydrogen peroxide once a day.
  B) Apply a lubricating lotion to the edges of the wound twice a day.
  C) Add more fruits and vegetables to your diet.
  D) Notify the healthcare provider if you notice swelling, warmth, or tenderness at the wound site.

[Zack0mack0101@yahoo.com]

Answer to Question 1

Answer: A, C, D, E

The techniques of inspection and palpation are especially important in assessing a client's immune system: The nurse will assess the client's general appearance, inspect the mucous membranes of the nose and mouth for color and condition, palpate the cervical lymph nodes for swelling or tenderness, and check the client's ROM, including that of the spine. While recommending that the client increase fluid intake may be an appropriate intervention, this is not an action that is conducted during the physical assessment for this client.

Answer to Question 2

Answer: D

A client being discharged with a surgical wound has to be instructed on the detection of infection, as the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. Applying lubricating lotion to the edges of a wound would impede the healing process.