The client admitted to the hospital for an arm fracture requiring surgery appears disheveled and has a body odor
The nurse expresses surprise at the client's appearance and reports that this is not the normal appearance of the client, who is usually clean and meticulously groomed. Based on this information, which assessments are priority to plan this client's care?
Select all that apply.
1. Food preferences.
2. Psychosocial assessment.
3. Memory assessment and orientation.
4. Spiritual assessment.
5. Body systems examination.
Correct Answer: 2, 3, 5
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. 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. The assessment of the client's body systems will yield clues as to the cause of the changes being noted in behavior. 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. A spiritual assessment is not a priority given the current assessment findings.
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a. Bringing up new problems b. Being absent from appointments c. Returning to maladaptive behavior d. Having increased anxiety
What physical changes will the nurse likely observe when assessing a patient during an acute panic attack? Select all that apply
1. Sweating 2. Trembling 3. Vomiting 4. Impaired cognition 5. Breathing difficulty
Confusion or disorientation can result from a decrease in the oxygen supply to the brain
Indicate whether the statement is true or false
A client has been diagnosed with a lymphatic system disorder. The client is eager to
know about the function of the specialized lymphatic capillaries. The nurse identifies which as the function of the specialized lymphatic capillaries? A) Help maintain blood pressure and circulating fluid volume B) Control the chemical and acid–base balance of the blood C) Provide thickness to the circulating blood volume D) Absorb digested fats and fat-soluble vitamins in the small intestine