Question

Judith Kline (J. K.), a 55-year-old woman, arrived at an urgent care center complaining of generalized malaise, an overwhelming feeling of exhaustion that was not relieved with rest, and difficulty walking more than 10 ft. She has thinning scalp hair, scaly skin, and puffiness around her eyes. She appears to be anxious. She is married and responsible for raising three grandchildren (2, 4, and 8 years old). She is employed full time as a college professor and is worried that she may have a serious condition that will compromise her ability to work and care for her grandchildren. She enjoys gardening and reading books. Her vital signs are: T 36° C (36.8° F), BP 102/68, P 68 and regular, and R 12 and unlabored.

1. Identify data that the nurse collected by looking at J. K.

2. Classify each piece of J.K.’s data in the case study as subjective or objective.

3. Write a minimum of five follow-up questions that the nurse should ask J. K. to obtain additional assessment data.

Answer 1

1.The data collected by looking at the J.K are

• Anxious
• Thinning scalp hair
• Scaly skin
• Puffiness around eyes
• Difficulty to walk

The observation shows that the patient is stressed out in how to manage raising her grandchildren

Thinning scalp hair ,puffy eyes, scaly skin ,malaise,exhaustion can be due to age,hormonal factors

Difficulty walking makes to suspect fir any arthritis or joint pain

2.Subjective data:

• Malaise
• Exhaustion on walking few feet

Objective data:

• Vitals:
  • T:36°C (normal)
  • P:668bpm
  • R:12 breath/ min
  • BP:102/68mmHg
• Inability to walk
• Scaly skin
• Thin hair
• Puffy eyes
• Anxious

3.The following questions can be asked to the to obtain additional assessment data

• Any medical conditions ,family history (DM,HTN,Osteoporosis or osteoarthritis, hypothyroidism, anxiety disorder)
• Any history of smoking, alcohol, tobacco, substance use to assess any problems associated due to it
• What stress management does she follows
• Food habits can be asked
• Exercise regimen
• Sumptoms associated to assess organ problems in specific