A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?

Respiratory rate

Weight

Current pain level

Level of orientation

Answer and Explanation

The Correct Answer is B

A. Respiratory rate:

Respiratory rate is not part of an anthropometric assessment. Anthropometry primarily focuses on physical measurements related to body size, composition, and proportions.

B. Weight:

Anthropometric assessment involves the measurement of various body dimensions, and weight is a

changes over time, and contribute to the overall understanding of a client's health and well-being.

C. Current pain level:

Pain level is not typically included in an anthropometric assessment. Anthropometry is more concerned with physical measurements and does not directly assess subjective experiences like pain.

D. Level of orientation:

Level of orientation is not a component of an anthropometric assessment. Anthropometry is concerned with objective physical measurements and does not assess cognitive or perceptual factors.

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Correct Answer is D

Explanation

A. Administer an antiemetic:

Administering an antiemetic might be necessary to relieve nausea and vomiting, but it is not the first action. Before administering medications, it is essential to assess the client's condition and gather information about the underlying cause of the symptoms.

B. Offer pain medication:

Offering pain medication is not the first action. The nurse needs to assess the client's condition, determine the cause of the pain, and gather more information before administering pain relief. Administering pain medication before a thorough assessment can mask important clinical signs and symptoms.

C. Palpate the abdomen:

Palpating the abdomen is an important step in the assessment, but it should follow auscultation of bowel sounds. Palpation can be deferred if there is concern about possible inflammation (as in suspected appendicitis) to avoid causing further irritation.

D. Auscultate bowel sounds:

This is the correct action. Auscultating bowel sounds is the first step in assessing the gastrointestinal (GI) function. The reported symptoms of right lower quadrant pain, nausea, and vomiting could be indicative of various GI issues, such as appendicitis. Assessing bowel sounds helps the nurse gather information about the status of peristalsis and potential obstructions.

A. "The higher the score, the higher the pressure injury risk." B. The client's age is part of the measurement." C. "Each element has a range from one to five points." D. "The scale measures six elements."

Correct Answer is D

Explanation

A. "The higher the score, the higher the pressure injury risk.":The Braden Scale measures pressure injury risk, but a higher score indicates a lower risk of developing a pressure injury.

B. "The client's age is part of the measurement.":The client’s age is not a direct factor measured by the Braden Scale.

C. "Each element has a range from one to five points.":Each element in the Braden Scale is scored from 1 to 4 points. A score of 1 indicates the highest level of impairment for that element, while a score of 4 indicates the least impairment.

D. "The scale measures six elements.":

The Braden Scale evaluates six elements:Sensory perception,Moisture,Activity,Mobility,NutritionandFriction/shear. These elements are critical for assessing a client’s risk of developing pressure injuries.

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A nurse is preparing to perform an anthropometric assessment on a client. Which of the following client data should the nurse include?

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