A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?
Edema
Heart Rate
Chills
Pallor
The Correct Answer is C
A. Edema:
Edema refers to the presence of swelling caused by an accumulation of fluid. While the nurse can observe and measure edema, the sensation of swelling itself is subjective and based on the client's perception.
B. Heart Rate:
Heart rate is an objective measure of the number of heartbeats per minute. It can be measured and observed by the healthcare provider, making it an objective data point.
C. Chills
Subjective data refers to information that is based on the client's personal experiences, perceptions, and feelings. Chills, which describe a feeling of coldness often associated with shivering, are a subjective symptom that the client experiences.
D. Pallor:
Pallor refers to an unusually pale or white skin color. While the nurse can observe and assess the color of the skin, the client's perception of pallor is subjective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.7"]
Explanation
To calculate the amount of hydroxyzine (Vistaril) to administer, use the formula:
D (desired dose) / H (have dose) x Q (quantity) = X (amount to give)
In this case, D = 35 mg, H = 50 mg/mL, and Q = 1 mL. Plug in the values and solve for X:
35 mg / 50 mg/mL x 1 mL = 0.7 mL
Therefore, the amount of hydroxyzine (Vistaril) to administer is 0.7 mL.
Correct Answer is A
Explanation
A. Take the blood pressure:
Assessing blood pressure is a critical initial step when a patient is experiencing dyspnea. It helps provide information about the patient's overall cardiovascular status, which is essential in determining the severity of the dyspnea and guiding subsequent interventions.
B. Remove the pillow from under the patient’s head:
Removing the pillow may be a relevant intervention if the patient is in a position that could be contributing to respiratory distress. However, the priority is to first assess vital signs, particularly blood pressure, to gather information about the patient's cardiovascular status.
C. Elevate the foot of the bed:
Elevating the foot of the bed may be a consideration if the dyspnea is related to conditions such as heart failure, where raising the legs can help reduce venous return and decrease the workload on the heart. However, the initial priority is to assess blood pressure to guide appropriate interventions.
D. Elevate the head of the bed:
Elevating the head of the bed may be beneficial for patients with respiratory distress to improve ventilation and oxygenation. While this intervention may be appropriate, the first action should be to assess vital signs, particularly blood pressure, to gain an overall understanding of the patient's condition.
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