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

Blood pressure

Cyanosis

Nausea

Petechiae

Answer and Explanation

The Correct Answer is C

Objective data:

Blood pressure (can be measured by the nurse)

Cyanosis (can be observed by the nurse)

Petechiae (can be observed by the nurse)

So, the subjective data in this list is "Nausea." This is information that the client shares with the nurse about their symptoms or feelings.

The objective data includes A-"Blood pressure," B-"Cyanosis," and D-"Petechiae," which are findings that the nurse can measure or observe during the physical examination.

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Correct Answer is A

Explanation

When a nurse observes another nurse acting flirtatiously and bringing small gifts to a client in the behavioral health unit, it raises concerns about professional boundaries and the potential for unethical behavior. The priority action for the observing nurse is to protect the rights and well-being of the client.

Option A, reporting the behavior to the supervisor, is the appropriate course of action. Reporting the observed behavior to the supervisor ensures that the situation is investigated and addressed by the appropriate authorities within the healthcare facility. This action helps maintain the integrity of the therapeutic relationship between the client and healthcare team and protects the client from any potential exploitation or manipulation.

Options B, C and D are not appropriate actions:

B. Ignoring the behavior is not appropriate as it does not address the concerns about professional boundaries and the potential for unethical behavior. Ignoring such behavior may allow it to continue, potentially putting the client at risk.

C. Confronting the nurse directly without first reporting the behavior to the supervisor may not be the most appropriate course of action. It is essential to involve the appropriate authorities within the healthcare facility to conduct a proper investigation and address the situation professionally.

D. Discussing the situation with the client and making assumptions about emotional manipulation may not be appropriate or accurate. It is not the observing nurse's role to discuss such matters with the client. Instead, the appropriate course of action is to report the observed behavior to the supervisor or appropriate authority within the healthcare facility.

Correct Answer is ["2"]

Explanation

To calculate the amount of naloxone to administer, you can use the following formula:

Amount to administer (mL) = Total dose required (mg) / Concentration of drug (mg/mL)

Given:

Total dose required = 0.4 mg

Concentration of drug = 0.2 mg/mL

Let's calculate the amount to administer:

Amount to administer (mL) = 0.4 mg / 0.2 mg/mL

Now, perform the calculation:

Amount to administer (mL) = 2 mL

So, the nurse should administer 2 mL of naloxone intravenously as a bolus dose to the client.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

Correct Answer is A

Explanation

Correct Answer is ["2"]

Explanation

A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

A client has just had an elective abortion to end an unintended pregnancy. Afterward, the client cries because although they wanted to have children in future years, this pregnancy was not well timed. Which type of grief is this client most likely to experience?

A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

An alert, oriented older adult client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which reason does the nurse identify is most likely why the client has not reported the abuse?

The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse. "What do you think about that?" Which is the best response by the nurse?

The health care provider prescribes haloperidol 10 mg for a client with severe psychosis but the client refuses the medication. Which nursing action is appropriate?

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin. 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?