A nurse on the Cardiovascular unit is completing the patient's history and physical examination. Which of the following information provided by the patient should the nurse consider as subjective data?
Cyanosis.
Petechiae.
Dizziness.
Blood pressure.
The Correct Answer is C
Choice A rationale:
Cyanosis - Cyanosis is a bluish discoloration of the skin and mucous membranes due to inadequate oxygenation of the blood. This is an objective sign that can be visually assessed, not based on the patient's description.
Choice B rationale:
Petechiae - Petechiae are small, pinpoint, red or purple spots on the skin caused by bleeding under the skin. Like cyanosis, this is a physical finding that can be observed directly.
Choice C rationale:
Dizziness - This is the correct choice. Dizziness is a subjective sensation that the patient experiences. It cannot be directly observed and relies on the patient's description of feeling unsteady, lightheaded, or having a spinning sensation.
Choice D rationale:
Blood pressure - Blood pressure is an objective measurement that can be taken using a blood pressure cuff and a stethoscope or automated device. It is not based on the patient's description and does not fall under subjective data.
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Related Questions
Correct Answer is B
Explanation
The correct answer is: d. Protective. Protective precautions are crucial for clients who have had an allogeneic hematopoietic stem-cell transplant due to their severely weakened immune systems.
Choice A reason:
Airborne precautions are used for infections that spread through the air, such as tuberculosis and measles. These infections require special ventilation and respiratory protection, which is not the primary concern for stem-cell transplant patients.
Choice B reason:
Contact precautions are used for infections spread by direct contact, like MRSA or C. difficile. These precautions involve wearing gloves and gowns but do not address the airborne or droplet risks that immunocompromised patients face.
Choice C reason:
Droplet precautions are for infections spread by large respiratory droplets, such as influenza or pertussis. While important, they do not provide the comprehensive protection needed for stem-cell transplant recipients.
Choice D reason:
Protective precautions involve placing the patient in a room with HEPA filtration and limiting visitors to minimize infection risk. This is essential for patients with compromised immune systems, such as those who have undergone allogeneic hematopoietic stem-cell transplants.
Correct Answer is A
Explanation
Choice A rationale:
It's essential to ensure that the client fully understands the surgical procedure and its implications before signing the informed consent form. If the client expresses confusion or lack of understanding, the nurse should involve the surgeon to address the concerns directly. The surgeon is the most appropriate person to provide comprehensive information about the procedure, potential risks, benefits, and alternatives. This promotes patient autonomy and informed decision-making, aligning with ethical principles.
Choice B rationale:
While educating the client about the procedure is important, it's not the nurse's role to provide detailed explanations of surgical procedures. Additionally, the surgeon possesses the necessary expertise to explain medical procedures accurately. Relying on the surgeon for this explanation maintains professional boundaries and ensures accurate information dissemination.
Choice C rationale:
Encouraging the client to reread the consent form is insufficient if the client did not initially understand the explanation. The consent form might contain complex medical language, and the client might need direct communication with the surgeon to address specific concerns. Merely re-reading the form might not alleviate the client's confusion.
Choice D rationale:
Telling the client that the surgeon will explain the procedure in the operating room is inappropriate. The client's concerns should be addressed promptly, and the explanation should occur before the surgery, allowing the client to make an informed decision. Operating rooms are not the appropriate setting for obtaining informed consent.
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