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
Option C demonstrates empathy and active listening. By acknowledging the client's emotions and expressing concern, the nurse creates a safe and supportive environment for the client to share their feelings. This response encourages the client to open up and express what they are going through, allowing the nurse to better understand the situation and provide appropriate care and support.
Options A and D are also empathetic but may not prompt the client to share their feelings or concerns as effectively as Option C.
Option B is not appropriate as it minimizes the client's emotions and may discourage them from expressing their feelings further.
Correct Answer is D
Explanation
Explanation: This response demonstrates the use of therapeutic communication, specifically offering the client an opportunity to express their feelings and concerns in a non-confrontational manner. By suggesting a private and quiet area to talk to, the nurse provides a safe and supportive environment for the client to explore and process their emotions. This approach can help the client feel heard, validated, and understood, which may reduce their need to act out or engage in argumentative behaviors to express their feelings.
The other responses are not as effective or therapeutic:
A. Threatening the client with seclusion is an aggressive approach and may escalate the client's behavior or cause them to feel cornered and defensive, leading to further acting out.
B. Telling the client they have to take medication to stop their behavior does not address the underlying issues that may be causing their behavior. It can also come across as dismissive of the client's feelings and concerns.
C. Saying "I don't know what set you off today but you have to get along with others" may be perceived as dismissive and does not offer the client an opportunity to express their emotions or address their concerns.
In summary, offering a private space to talk and explore the client's feelings in a non-judgmental and supportive manner is the most beneficial therapeutic response to help the adolescent client decrease acting out behaviors and promote positive communication and coping skills.
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