Author Question: The nurse is preparing to assess the general appearance of the hospitalized client. Which statements ... (Read 51 times)

silviawilliams41 · **on:** Jun 25, 2018

The nurse is preparing to assess the general appearance of the hospitalized client. Which statements by the client are expected if the client is experiencing undernutrition? Select all that apply.

1. It seems like I catch every bug that comes along. I can't seem to stay well.
2. This wound that I've had for the last 3 months on my leg won't heal.
3. I have gained five pounds over the last week and my ankles and feet are swollen.
4. My nails are so brittle.
5. I know my blood pressure has been up because I've been experiencing headaches in the morning, just like last time.

Question 2

The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes. Which statement by the student nurse indicates that further education is required?

1. The rapid assessment should last approximately 10 minutes.
2. I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care.
3. The rapid assessment will help me establish baseline data about the client.
4. After I perform the rapid assessments on the clients I've been assigned, I can go back and get more information during my routine assessments.

LP · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Correct Answer: 1, 2, 4
Undernutrition can lead to a compromised immune status, poor wound healing, and the development of brittle nails and hair. Edema in the feet and ankles along with weight gain is often associated with a poor cardiovascular status or renal insufficiency. These types of signs are not typically associated with undernutrition. The client with hypertension can experience headaches in the morning. Hypertension is not typically associated with undernutrition.

Answer to Question 2

Correct Answer: 1
The nurse should be able to perform the rapid assessment within 1 minute, not 10 minutes. It will be helpful for the nurse to help plan care for the clients that have been assigned to the new nurse by performing rapid assessments at the beginning of the shift on all of the assigned clients. The rapid assessment helps the nurse establish baseline data about the client. Following the rapid assessment, the nurse can go back later and perform a routine assessment to gather more information about the client.