The nurse in the clinic is preparing to perform a physical assessment on a client who arrived for a routine check-up. Before beginning the assessment, which four activities should the nurse carry out? (Select all that apply.)
Wash hands
Provide patient privacy
Obtain a provider healthcare order
Position the client comfortably on the sturdy examination table
Explain the procedure to the client
Correct Answer : A,B,D,E
A. Washing hands is a crucial step to prevent infection and maintain hygiene before any physical assessment.
B. Providing patient privacy is essential to ensure the client's comfort and confidentiality during the assessment.
C. While it’s important to follow the provider’s orders, a routine check-up typically does not require a new healthcare order, as the nurse can perform the assessment as part of standard care.
D. Positioning the client comfortably on the examination table is necessary to facilitate the assessment and ensure the client's comfort during the procedure.
E. Explaining the procedure to the client helps to alleviate anxiety, improve understanding, and foster cooperation during the assessment.
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Correct Answer is B
Explanation
A. The planning phase involves setting goals and determining interventions based on the assessment data.
B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.
C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.
D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.
Correct Answer is A
Explanation
A. Vitamin D deficiency is a modifiable risk factor because it can be addressed through dietary changes, supplements, and increased sun exposure.
B. A small-boned, thin frame is considered a nonmodifiable risk factor as it is a genetic characteristic that cannot be changed.
C. A personal history of fractures is also a nonmodifiable risk factor, as past fractures indicate an increased risk for future fractures and cannot be altered.
D. Age is a nonmodifiable risk factor, as it is an intrinsic characteristic that cannot be changed.