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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Related Questions
Correct Answer is C
Explanation
When dealing with a client who is manipulative and disruptive but not demonstrating behaviors that are a threat to self or others, it is essential for the nurse to set clear and consistent boundaries for behavior. This helps establish a therapeutic environment and maintains the safety and well-being of both the client and others in the milieu.
Allowing the client to refuse medications is an important aspect of respecting their autonomy and right to make decisions about their own care, as long as they are not posing a risk to themselves or others. It is important to communicate with the client about the potential consequences of refusing medications and provide information about the benefits of taking prescribed medications to support their mental health.
The other options are not appropriate for the following reasons:
A- Informing the client that a family member will be called to help: Involving family members can be helpful in some situations, but it should not be used as a way to manipulate the client into compliance with treatment. Calling a family member without the client's consent may also violate the client's privacy and autonomy.
B- Preparing discharge paperwork since the client is refusing assistance: Discharging the client solely because they are refusing medication may not be appropriate or ethical if they are not posing a threat to themselves or others. Discharging the client without addressing the underlying issues may not be in the client's best interest and may not resolve the disruptive behavior.
D- Informing the client that without medications, their mental status will not improve: While it is important to provide the client with information about the benefits of medication, using this information as a threat or coercion tactic may not be therapeutic or effective. The nurse should focus on building a trusting relationship with the client and supporting them in making informed decisions about their care.
Correct Answer is D
Explanation
A-Positioning in semi-Fowler’s can aid breathing but doesn’t assess crackles’ cause. It’s supportive, not diagnostic, and premature without further data
B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.
C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.
D- Reassessing after deep breathing and coughing evaluates secretion clearance, aligning with nursing assessment and Maslow’s physiological needs
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