Nursing Assessment for Systemic Symptoms
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Client presents with fatigue and a temperature of 101.3°F (38.5°C). The client also has bruises at varying degrees of healing and reports 10 lb (4.5 kg) unintentional weight loss over the past 2 months. Which assessments will the nurse perform to help identify the possible cause of these symptoms? Select all that apply.
- Obtain fasting blood glucose level.
- Evaluate for hearing loss.
- Draw blood for complete blood count (CBC).
- Ask about recent history of infections.
- Palpate lymph nodes.
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Step by Step Written Solution
Hello! Let's analyze this clinical scenario to determine which assessments a nurse should perform. First, we will identify the key findings in the patient's presentation.
Clinical Presentation Analysis
The patient is presenting with fatigue and a fever of one hundred and one point three degrees Fahrenheit. These are foundational signs of possible infection or systemic illness.
1. Fatigue & Fever ($101.3^{\circ}F/38.5^{\circ}C$)
Crucial details include bruising at varying stages of healing and a ten-pound unintentional weight loss over just two months. These symptoms combined—fever, fatigue, bruising, and weight loss—strongly suggest possible hematologic disorders, such as leukemia or lymphoma.
2. Ecchymosis (Bruising) at varying healing stages
3. Unintentional weight loss (10 lbs in 2 months)
Now, let's evaluate each option to see if it helps identify the cause of these specific symptoms.
Assessing the Options
| Option | Relevant? | Reason |
|---|---|---|
| Obtain fasting blood glucose | No | Diabetes doesn't typically cause fever/bruising. |
| Evaluate for hearing loss | No | Not related to systemic fatigue/weight loss. |
| Draw blood for CBC | Yes | Checks for abnormal white cells, anemia, or low platelets. |
| Ask about history of infections | Yes | Helps identify immunosuppression or leukemia trends. |
| Palpate lymph nodes | Yes | Checks for malignancy like lymphoma or infection response. |
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