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 C

Explanation

During the introductory (orientation) phase of the nurse-client relationship, the nurse should focus on establishing trust and rapport with the client. One way to do this is by eliciting information from the client through active listening and open-ended questioning. This allows the nurse to gather important information about the client's health status, needs, and concerns and helps to establish a foundation for the therapeutic relationship. Reviewing progress toward personal objectives and encouraging self-exploration is more appropriate for later phases of the relationship.

Talking with others who have information about the client may also be helpful, but it is important to prioritize direct communication with the client during this phase.

A. Reposition the client every 3 hours. B. Apply cornstarch to keep the skin dry. C. Provide the client with a diet high in protein. D. Massage bony prominences to promote circulation.

Correct Answer is C

Explanation

A diet high in protein can help maintain skin integrity in older adults. Protein is essential for tissue repair and wound healing. The other options may not be as effective in maintaining skin integrity. For example, repositioning the client every 3 hours may not be frequent enough to prevent pressure ulcers. Applying cornstarch to keep the skin dry may not be the best option as it is important to keep the skin moisturized. Massaging bony prominences to promote circulation may not be recommended as it could cause damage to fragile skin.

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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

A nurse is caring for a client in the introductory (orientation) phase of the nurse-client relationship. Which of the following communication techniques should the nurse use during this phase?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

Correct Answer is C

Explanation

A nurse is taking care of an adult client who throws a temper tantrum because he does not get his own way. Which defense mechanism is the adult client displaying?

A client is hospitalized with numerous acute health problems. According to Maslow's hierarchy of needs model, which nursing diagnosis should the nurse identify as being the highest priority for this client?

The nurse instructs the client on mind-body therapies. Which mind-body therapy is used when the client pictures themselves lying on a beach with the sounds of waves, the cries of seagulls, and the warmth of the sun during periods of stress?

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?

Which of the following statements is true regarding types of health care agencies?

When a labor and delivery nurse tells a co-worker that a client of Asian descent probably did not want any pain medication because "Asian women typically are stoic," the nurse is expressing a belief known as what?

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+ and equal in radial, popliteal, and dorsalis pedis. What does the number "+3" represent?