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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.

A. Malpractice B. Battery C. False imprisonment D. Assault

Correct Answer is A

Explanation

The potential issue that the nursing staff and hospital may have to defend against in this scenario is A. "malpractice."

Explanation: Malpractice refers to a legal claim that can be made against healthcare professionals, including nurses and hospitals, when they fail to provide the standard of care expected in their profession, resulting in harm or injury to a patient. In this case, the lack of documentation that the client was assessed every hour as prescribed can be seen as a failure to meet the standard of care for a client with depression, especially one at risk for self-harm or suicide. If the client attempted suicide in the bathroom and sustained an injury, it could be argued that the lack of proper assessment and monitoring contributed to the client's harm, and this failure to provide appropriate care might be considered malpractice.

The other options, "battery," "false imprisonment," and "assault," do not directly relate to the situation described in the scenario:

B- Battery refers to the intentional harmful or offensive contact with a person without their consent. There is no indication that this occurred in the scenario.

C- False imprisonment refers to the unlawful restraint or restriction of a person's freedom of movement without proper justification. There is no indication of false imprisonment in the scenario.

D- Assault refers to the intentional act of threatening or causing fear of harm to another person. While the client did sustain an injury, there is no indication that it was due to an intentional act of assault in this scenario.

In summary, the potential issue of malpractice arises from the failure to properly assess and monitor a client at risk for self-harm, resulting in harm to the client. The nursing staff and hospital may have to defend against this claim if it is determined that they did not meet the standard of care expected in such a situation.

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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

A client with depression is found to have attempted suicide in the bathroom and sustained injury. There is no documentation that the client was assessed every hour as prescribed. Which issue will the nursing staff and hospital potentially have to defend against?

Correct Answer is A

Explanation

The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

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?

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A nurse cared for a terminally ill client for over a month and developed a therapeutic nurse-client relationship. After the client's death, feelings of sadness. sleeping poorly, and feeling mildly depressed were experienced by the nurse. Which is the best action to improve the resolution of grief?

A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?

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 nurse working in an outpatient clinic is performing an intake assessment for a female client. Which priority question will the nurse ask the client as part of the initial assessment?