A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as
The patient has low blood pressure.
The patient is short of breath.
The patient has wound drainage.
The patient reports feelings of fatigue.
The Correct Answer is D
A: Low blood pressure is an objective finding that can be measured directly.
B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.
D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Anisocoria refers to a condition where the pupils are of unequal sizes, which is not related to focusing ability.
B: Accommodation response involves the ability of the eye to change focus from distant to near objects, demonstrating the flexibility of the lens which is exactly what the instruction aims to test.
C: Direct pupil response relates to pupil constriction in response to light, not changes in focal distance.
D: Consensual reflex also refers to the reaction of both pupils to light and would not be assessed through changes in focal distance.
Correct Answer is A
Explanation
A: Due to age-related reductions in gastrointestinal muscle efficiency, which slows the digestive process and can lead to increased water absorption from stool.
B: Overstates the issue, not all elderly patients experience difficulties, and it does not account for individual variability or other influencing factors like diet and medication.
C: Misrepresents the frequency and reasons for laxative use among the elderly, not all of whom misuse these medications.
D: While changes in rectal sphincter elasticity can affect some elderly individuals, it is less commonly a direct cause of constipation compared to decreased peristalsis.
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