The nurse is conducting a physical assessment for a client with a compromised immune system. Which actions by the nurse are appropriate?

Question

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

Answer 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.