A 17-year-old male patient presents to the Emergency Department (ED) after a skydiving accident and tells the nurse that he is very anxious, is nauseated, and feels hot. These types of data would be:
Objective Data
Introspective Data
Subjective Data
Reflective Data
The Correct Answer is C
Choice a reason:
Objective data refers to information that is observable and measurable by the healthcare provider, such as vital signs, physical examination findings, and laboratory results. The patient's statements about his feelings are not objective data because they cannot be directly measured or observed by the nurse.
Choice b reason:
Introspective data is not a commonly used term in healthcare. Introspection generally refers to the examination of one's own conscious thoughts and feelings, which in the context of healthcare, can be part of subjective data as it is reported by the patient.
Choice c reason:
Subjective data consists of information that is reported by the patient, including feelings, perceptions, and concerns. It is called 'subjective' because it is based on the patient's personal experience and cannot be independently verified by the nurse. In this case, the patient's report of feeling anxious, nauseated, and hot is considered subjective data.
Choice d reason:
Reflective data is not a standard term in healthcare documentation. Reflection is a process of personal thought and does not pertain to the clinical data gathered during a patient assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Diabetes mellitus is not typically associated with pitting edema unless it has led to a comorbid condition such as heart failure or kidney disease. Pitting edema is more commonly associated with fluid retention due to the body's inability to manage fluid balance, which is not a direct consequence of diabetes mellitus itself.
Choice B reason:
Liver disease, particularly cirrhosis, can lead to pitting edema. The liver's inability to produce albumin, a protein that helps maintain oncotic pressure in the blood vessels, and portal hypertension, which is an increase in the blood pressure within the portal vein system, can both contribute to the development of pitting edema.
Choice C reason:
End-stage renal disease can also cause pitting edema due to the kidneys' inability to excrete excess fluid. However, the edema associated with renal disease is often more generalized and not limited to the lower extremities.
Choice D reason:
Colon cancer is not typically associated with pitting edema unless it has metastasized and caused secondary complications that affect the liver or the heart. Pitting edema is not a direct symptom of colon cancer itself. 
Correct Answer is C
Explanation
Choice A Reason:
Positioning the arm below waist level is not recommended when measuring blood pressure. It can result in an inaccurate reading, typically showing a higher blood pressure due to the effects of gravity on the blood column. The arm should be positioned at heart level for an accurate measurement.
Choice B Reason:
While palpating the radial artery to confirm a pulse is present is part of the overall assessment of circulation, it is not a necessary step immediately before measuring blood pressure. The focus should be on ensuring the client is in the correct position and is relaxed to avoid any factors that might artificially alter the blood pressure reading.
Choice C Reason:
Asking the client to sit quietly in a chair for 5 minutes is the correct procedure before measuring blood pressure. This allows the client's heart rate and blood pressure to stabilize, providing a more accurate measurement. Any activity or stress can temporarily raise blood pressure, so this quiet time is crucial.
Choice D Reason:
The arm selected for blood pressure measurement should not be covered with clothing. Clothing can constrict the blood pressure cuff and interfere with the accuracy of the reading. The cuff should be placed on bare skin to ensure it inflates and deflates correctly and that the stethoscope can accurately detect the sounds of the blood flow.
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