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. Elevate full-length side rails on both sides of the client's bed:

While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.

B. Place the bedside table 0.9 m (3 feet) away from the bed:

Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.

C. Keep the client's room temperature at 18°C (64.4°F):

While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.

D. Provide the client with a night light:

This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.

A. Assist the client with a bowel cleansing. B. Ensure the client is free of metal objects. C. Monitor the client for pain in the suprapubic region. D. Administer 240 mL. (8 oz) of oral contrast before the procedure

Correct Answer is A

Explanation

A. Assist the client with a bowel cleansing.A bowel cleansing is necessary before an intravenous pyelogram (IVP) to ensure the urinary tract is clearly visualized on the X-ray images. Residual stool or gas in the intestines can obscure the view of the kidneys, ureters, and bladder.

B.Ensure the client is free of metal objects.While ensuring the client is free of metal objects is critical for procedures involving magnetic resonance imaging (MRI) or X-rays of the skeletal system, it is not specifically required for an IVP.

C.Monitor the client for pain in the suprapubic region.Monitoring for suprapubic pain is more relevant after procedures such as catheterization or bladder studies, or in cases of suspected urinary retention or infection.

D.Administer 240 mL (8 oz) of oral contrast before the procedure.An IVP involves injecting contrast dye intravenously, not orally. Oral contrast is typically used for gastrointestinal studies, such as a CT scan of the abdomen or barium swallow.

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