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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Prior to meeting with a client who is experiencing complicated grieving, the nurse should engage in self-reflection and examine their own attitudes, biases, and emotional responses related to loss and grieving. This is important because the nurse's own experiences and beliefs can influence their ability to provide empathetic and non-judgmental care to the client. By acknowledging and understanding their own feelings and reactions, the nurse can better support the client in their grieving process.
The other options are not appropriate for the following reasons:
B- Evaluating previous methods of interventions: While it is essential for the nurse to have knowledge and skills related to grief counseling and interventions, focusing solely on previous methods may not be helpful for the client's unique situation. Each individual's grieving process is different, and what worked for one client may not work for another.
C- Establishing goals for the process and presenting them to the client: While setting goals for the therapeutic relationship is important, it should be a collaborative process between the nurse and the client. The nurse should work with the client to identify their needs and goals related to the grieving process and develop a plan of care together.
D- Sharing personal information related to loss experienced by the nurse: It is not appropriate for the nurse to share their own personal experiences of loss with the client. The focus of the therapeutic relationship should be on the client's needs and experiences, not the nurse's. Sharing personal information can shift the focus away from the client and may not be helpful or therapeutic for them.
Correct Answer is B
Explanation
When a client has an angry outburst and then quickly appears calmer and receptive to input from the nurse, it is important for the nurse to address the underlying cause of the outburst and explore the client's feelings and emotions. By asking, "What happened that got you so upset?", the nurse is inviting the client to express their feelings and share what triggered their anger. This can help the nurse understand the client's perspective, provide appropriate support, and potentially de-escalate any remaining tension or frustration.
The other options are inappropriate because:
A- "We will have to talk about this later." This response may make the client feel dismissed or that their feelings are not being heard or understood.
C- "You really scared me. I'm glad you are okay." While this response acknowledges the client's emotional state, it centers the focus on the nurse's feelings rather than exploring the client's perspective or emotions.
D- "Your behavior is unacceptable and will not be tolerated." This response is confrontational and judgmental, which can escalate the situation and potentially trigger further defensive reactions from the client.
Overall, a non-judgmental and empathetic approach that focuses on understanding the client's feelings and experiences is more likely to foster open communication and provide the client with a safe space to express themselves.
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