During a discussion between the student nurse and nurse about the results of a client's nutritional assessment, the student nurse asks, "Which one of the pieces of the nutritional assessment is least important?" Of the following responses,

which one is the nurse's best response? 1. "The nutrition history is most important because it helps us understand how the client has been eating.".
2. "The head-to-toe physical assessment is most important because it helps us see how the client's nutritional status is affecting their body.".
3. "The laboratory-based diagnostic tests are most important because they give us information about something that may be happening within the client's body that we weren't able to find during the physical assessment.".
4. "Actually, every piece of the nutritional assessment is important. They have to be used together to paint the most complete picture of the client's nutritional status.".


4

Rationale: A nutritional assessment is comprised of the nutrition history, physical assessment, and laboratory diagnostic testing. Each piece provides specific information that must be combined together to create the entire picture about what is happening with the client. No single piece of the assessment is more important than another piece.

Nursing

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As death approaches, a patient with AIDS says, "I do not have enough energy for many visitors anymore, and I am embarrassed about how I look. I only want to see my parents and sister.". What action should the nurse take?

a. Support the patient to share the request with the parents and sister. Suggest that they inform the patient's friends of the request. b. Encourage the patient to reconsider this decision. Interested and caring friends can be sources of support. c. Suggest that the patient discuss these wishes with the health care provider. d. Place a "No Visitors" sign on the patient's door.

Nursing

A client with extreme fatigue is being interviewed by the nurse. The client reports a sore tongue and frequent bouts of diarrhea. The nurse should suspect that the client is experiencing:

1. Folic acid deficiency. 2. Lymphedema. 3. A lack of iron in the diet. 4. Pernicious anemia.

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A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy to

A) Replace fluid and electrolytes B) Administer blood products C) Provide protein supplements D) Treat the client's infection

Nursing

When washing the perineal area, use a large amount of soap, because this area is very contaminated.

Answer the following statement true (T) or false (F)

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