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
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 C
Explanation
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.
Correct Answer is C
Explanation
The client's observed behavior of pacing the hall with clenched fists and swearing at others indicates that they are in the escalation phase of the aggression cycle. During this phase, the individual's anger and agitation increase, and their behavior becomes more intense and aggressive. If not addressed promptly and effectively, the situation can escalate further and potentially lead to a crisis or violent outburst.
By intervening immediately and calmly, the nurse aims to prevent the situation from escalating further and moving into the crisis phase, where the risk of harm to the client and others is highest. Effective de-escalation techniques, such as using a calm and non-threatening demeanor, active listening, and providing clear and respectful communication, can help the client regain control and reduce their agitation.
Option A - Recovery: The recovery phase comes after the aggressive incident, during which the individual may feel remorse or embarrassment about their behavior.
Option B - Crisis: The crisis phase is the point where the individual's anger and agitation reach a peak, and there is a high risk of violence or harmful actions.
Option D - Triggering: The triggering phase is the initial phase of the aggression cycle, where the individual's anger begins to build, and certain triggers may set off their aggressive behavior.
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