The nurse is conducting a physical assessment for a client with a compromised immune system. Which actions by the nurse are appropriate? Select all that apply.
A)Assessing general appearance
B)Recommending increased fluid intake
C)Inspecting the mucous membranes of the nose and mouth
D)Palpating the cervical lymph nodes
E)Checking joint range of motion (ROM), including that of the spine

Question

Quizplus · Accepted Answer

A)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. Although recommending that the client increase fluid intake may be an appropriate nursing intervention, it is not an action that is conducted during the physical assessment for this client.
B)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. Although recommending that the client increase fluid intake may be an appropriate intervention, it is not an action that is conducted during the physical assessment for this client.
C)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. Although recommending that the client increase fluid intake may be an appropriate intervention, it is not an action that is conducted during the physical assessment for this client.
D)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. Although recommending that the client increase fluid intake may be an appropriate intervention, it is not an action that is conducted during the physical assessment for this client.
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. Although recommending that the client increase fluid intake may be an appropriate intervention, it is not an action that is conducted during the physical assessment for this client.

The Nurse Is Conducting a Physical Assessment for a Client