A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

A. Level of orientation:

The level of orientation refers to the client's cognitive status and ability to understand their surroundings. While important for overall assessment and care planning, it is not typically included in anthropometric assessment, which focuses specifically on physical measurements and characteristics of the body.

B. Respiratory rate:

Respiratory rate is a vital sign that reflects the client's respiratory status and is important for assessing oxygenation and ventilation. However, it is not part of anthropometric assessment, which primarily focuses on physical measurements related to body size, shape, and composition.

C. Weight

Anthropometric assessment involves the measurement of various body dimensions, such as height, weight, and body composition. Weight is a crucial component of anthropometric assessment as it provides information about the client's nutritional status, growth patterns, and overall health. Monitoring changes in weight over time can help identify trends and assess the effectiveness of interventions aimed at improving nutritional status or managing health conditions.

D. Current pain level:

Pain level is important for assessing the client's comfort and managing pain effectively, but it is not included in anthropometric assessment. Anthropometric assessment focuses on objective measurements of body dimensions and characteristics rather than subjective experiences such as pain.

A. Social worker:

While social workers play a vital role in addressing psychosocial needs and connecting clients with community resources, they typically do not have the specialized skills or training to address the physical limitations associated with feeding difficulties due to rheumatoid arthritis. Therefore, a referral to a social worker may not directly address the client's need for assistance with feeding.

B. Occupational therapist

Occupational therapists specialize in helping individuals regain or maintain independence in performing activities of daily living (ADLs), including feeding oneself. In the case of a client with severe rheumatoid arthritis in her hands who is unable to feed herself, an occupational therapist can assess the client's abilities, provide interventions such as adaptive equipment or techniques to facilitate feeding, and offer strategies to improve hand function and joint mobility. They can also collaborate with the client and other members of the healthcare team to develop a customized plan of care to address the client's specific needs and goals related to feeding and self-care.

C. Physician assistant:

Physician assistants work closely with physicians to provide medical care and may be involved in diagnosing and managing various health conditions. However, they do not typically provide specialized rehabilitation services or interventions related to activities of daily living such as feeding. Therefore, a referral to a physician assistant may not address the client's specific need for occupational therapy services.

D. Physical therapist:

Physical therapists specialize in restoring mobility, strength, and function, primarily focusing on gross motor skills and movement patterns. While physical therapists may address certain aspects of hand function and mobility, they do not specialize in activities of daily living such as feeding. Therefore, a referral to a physical therapist may not directly address the client's need for assistance with feeding due to severe rheumatoid arthritis in her hands.