A client is admitted to the orthopedic unit after breaking an arm after a fall. The client appears disheveled and has a body odor. The family arrives and expresses surprise at the client's appearance

Question

They report that this is not the normal appearance of the client and that they are usually clean and meticulously groomed. Which of the following assessments does the nurse need to complete in order to formulate relevant nursing diagnoses and a plan of care for this patient? Standard Text: Select all that apply. 1. Food preferences
2. Psychosocial assessment
3. Memory assessment and orientation
4. Family medical history
5. Body systems examination

Answer 1

2,3,4,5
Rationale 1: Food preferences. Collection of dietary preferences is completed on clients when they are admitted to a facility, however, this information will not provide an explanation for the changes being noted in the client's behaviors.
Rationale 2: Psychosocial assessment. The client's appearance indicates there has been some change in mental outlook or condition. These changes may be the result of psychosocial issues and they must be investigated.
Rationale 3: Memory assessment and orientation. The client's appearance indicates there has been some change in mental outlook or condition. The client's memory and level of orientation will provide information relating to potential causes. This assessment will also provide an indication as to the seriousness of the problems being noted.
Rationale 4: Family medical history. The client's presentation is indicative of a problem. Some disorders may be genetic, thus requiring investigation.
Rationale 5: Body systems examination. The assessment of the client's body systems will yield clues as to the cause of the changes being noted in behavior.