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
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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Related Questions
Correct Answer is D
Explanation
A: Placing the client supine with knees bent can help reduce strain on the abdominal area but is not the immediate first action.
B: Raising the head of the client’s bed 15 to 20 degrees is not the priority action in this situation.
C: Assessing the client for manifestations of shock is important but should follow the immediate action of protecting the eviscerated wound.
D: Covering the area with a sterile dressing moistened with 0.9% sodium chloride irrigation is the correct first action. This helps protect the exposed organs and tissues from contamination and keeps them moist until surgical intervention can be performed.
Correct Answer is B
Explanation
A: Continuous output from the stoma is expected in patients with an ileostomy. The stoma continuously produces waste, and this is a normal finding.
B: The presence of blood in the stool is an abnormal finding and should be reported immediately. It could indicate bleeding within the gastrointestinal tract, which requires prompt medical evaluation and intervention.
C: Malodorous stool is common with an ileostomy and is not typically a cause for immediate concern. However, if the odor is unusually strong or different, it may warrant further investigation.
D: Liquid consistency of stool is normal for an ileostomy, as the large intestine, which absorbs water, is bypassed. This is not an immediate concern unless there are other symptoms present.
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