A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

Petechiae

Blood pressure

Nausea

Cyanosis

Answer and Explanation

The Correct Answer is C

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

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Correct Answer is B

Explanation

A: The client attempting to remove the restraint does not necessarily indicate a need to loosen it. The nurse should assess the reason for the client’s behavior.

B: The client’s hand being cold and pale indicates compromised circulation, which requires immediate loosening of the restraint to restore blood flow.

C: Full range of motion in the wrist suggests that the restraint is not too tight and does not need to be loosened.

D: A capillary refill of less than 2 seconds indicates good circulation, so the restraint does not need to be loosened.

A. “I will clean the hearing aids with alcohol wipes.” B. “I will expect the hearing aids to whistle when I cup my hand over them.” C. “I will not use hairspray if I am wearing the hearing aids.” D. “I will change the batteries once a week.”

Correct Answer is A

Explanation

A: Cleaning hearing aids with alcohol wipes is not recommended as it can damage the devices. The client should use a soft, dry cloth or a cleaning tool designed for hearing aids.

B: Expecting the hearing aids to whistle when cupping a hand over them is normal. This feedback occurs due to the sound being reflected back into the microphone.

C: Not using hairspray while wearing hearing aids is correct. Hairspray can clog the microphone and other components of the hearing aids.

D: Changing the batteries once a week is a reasonable practice, depending on the usage and type of hearing aids. This statement does not indicate a need for further instruction.

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A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

Correct Answer is B

Explanation

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

Correct Answer is A

Explanation

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