During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed and says "leave me alone." Which subjective data should the nurse document?

Not talkative

Pale and diaphoretic

"Leave me alone"

Restlessness

Encourage or provide oral hygiene after mealtime.

Answer and Explanation

The Correct Answer is C

Subjective data refers to information that is reported by the client and cannot be directly observed or measured by the healthcare provider. In this case, the statement "leave me alone" is an example of subjective data that the nurse should document. This information provides insight into the client's feelings and emotions and can help guide the nurse's care and interventions.

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Correct Answer is D

Explanation

A stage II pressure ulcer is a wound that involves partial-thickness loss of skin. The most appropriate NANDA nursing diagnosis problem statement for a client with this condition would be Impaired Skin Integrity. This diagnosis reﬂects the fact that the client's skin has been damaged and is no longer intact. Risk for Injury, Altered Tissue Perfusion, and Impaired Tissue Integrity are also NANDA nursing diagnoses, but they are not as specific or relevant to the client's condition as Impaired Skin Integrity.

A. Hallucinations at the onset of sleep B. Sleep apnea C. A lack of rapid eye movement (REM) sleep D. The urge to move the legs when trying to sleep E. Sudden attacks of sleep

Correct Answer is ["A","B","E"]

Explanation

During an assessment of a client diagnosed with narcolepsy, the nurse should anticipate the following findings: Hallucinations at the onset of sleep, Sleep apnea, and Sudden attacks of sleep ². These are common symptoms of narcolepsy. The other options (A lack of rapid eye movement (REM) sleep and The urge to move the legs when trying to sleep) are not directly related to narcolepsy.

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During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed and says "leave me alone." Which subjective data should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client has a documented stage II pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate to use with this client?

Correct Answer is D

Explanation

A nurse is conducting an assessment on a client diagnosed with narcolepsy. The nurse should anticipate which of the following findings? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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