The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

A. The presence of crepitus, regardless of size, indicates air trapped in the subcutaneous tissue, which can be associated with various conditions including trauma, infection, or underlying lung issues. Therefore, it is important to evaluate the finding further rather than assuming it is insignificant.
B. This is the most accurate interpretation. Crepitus is indeed an abnormal finding and warrants further investigation. Its presence can indicate underlying issues such as subcutaneous emphysema, which may be related to trauma, infections, or other conditions that need to be addressed. A more detailed assessment, including possible imaging or additional diagnostic tests, should be pursued to determine the cause and appropriate management.
C. While it is true that subcutaneous air can be absorbed over time, the presence of crepitus is still an abnormal finding that needs to be evaluated. The underlying cause of the trapped air must be identified, as it may indicate an injury or other health issues that require intervention. Simply assuming that it will resolve on its own without further investigation could overlook a potentially serious condition.
D. While a fractured rib can cause crepitus, this finding alone does not necessarily mean an immediate chest x-ray is required. The decision to order an x-ray should be based on a comprehensive assessment of the client’s symptoms, history, and physical examination findings. Although a rib fracture is a possible cause, other conditions such as subcutaneous emphysema or infections should also be considered.

A. The numeric pain intensity scale is a direct and effective method to assess the level of pain a patient is experiencing. If a client is splinting their chest, it’s essential to evaluate their pain level to determine the severity and guide appropriate pain management strategies. This is likely the most relevant and immediate follow-up assessment in this scenario.
B. An apical-radial pulse deficit measures the difference between the apical pulse (heart rate auscultated at the apex of the heart) and the radial pulse (heart rate palpated at the wrist). This assessment is used to detect conditions such as atrial fibrillation or other arrhythmias and is not directly related to the client’s chest splinting. Therefore, it is not the most relevant follow-up assessment in this context.
C. The anteroposterior (AP) chest diameter assessment is used to evaluate conditions such as barrel chest, which can be associated with chronic respiratory conditions. While this measurement can be important for assessing chronic respiratory issues, it is not directly related to the immediate concern of chest splinting, which is more likely associated with acute pain or discomfort.
D. Measuring body temperature is important for assessing the presence of fever or infection, but it does not directly address the client’s immediate complaint of chest pain or discomfort. While an elevated temperature might be relevant if an infection is suspected, it is not the most direct or immediate follow- up assessment for the observed behavior of splinting the chest.