A nurse is caring for a client who is scheduled for surgery.

Exhibit 1

Medical History

0800:

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.

Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points)

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply

A. Move items in the room away from the client: During a seizure, the client may have uncontrolled movements that could cause them to hit nearby objects and potentially injure themselves. Moving items away from the client helps create a safer environment and reduces the risk of injury from contact with objects.

B. Loosen the client's clothing: Seizures can lead to muscle contractions and movements that might constrict the client's clothing, particularly around the neck or chest area. Loosening the client's clothing helps ensure that their breathing is not restricted during the seizure.

C. Turn the client onto their side: Turning the client onto their side is an important step for airway protection. During a seizure, there is a risk of saliva or vomit obstructing the airway, which can lead to aspiration. Turning the client onto their side helps prevent aspiration by allowing any fluids to drain out safely and maintaining an open airway.

D. Help the client lie on the floor: If the client is seated in a chair during a seizure, it's safer to assist them in lying on the floor. This action prevents the client from falling out of the chair and potentially sustaining injuries from the fall. Once on the floor, the nurse can continue to monitor the client and provide appropriate care and support.

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.