A 76-year-old client presents to the outpatient clinic with complaints consistent with influenza. During the interaction, the nurse notes the client's clothing appears too large
Which of the following actions by the nurse should be performed first? 1. Document the findings.
2. Report the findings to the healthcare provider.
3. Contact social services.
4. Engage the client in a discussion regarding dietary practices.
4
Rationale 1: The findings must be documented but should be done after the interaction is finished. The nurse needs to determine the reason for the client's weight loss by conversing with the client.
Rationale 2: At this point, there is no need to consult with the healthcare provider. The nurse needs to determine the reason for the client's weight loss by conversing with the client.
Rationale 3: At this point, there is no need to contact social services. The nurse needs to determine the reason for the client's weight loss by conversing with the client.
Rationale 4: Baggy clothing may be reflective of recent weight loss. Obtaining information needed to assess for nutritional problems and dietary practices can best be assessed by conversation between the client and nurse.
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