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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nursing process consists of five phases: assessment, diagnosis, planning, implementation, and evaluation. During the assessment phase, the nurse gathers information about the client's health status and needs. In this scenario, the nurse is conducting a dressing change and notes a new area of skin breakdown. This observation is part of the assessment phase of the nursing process, as the nurse is gathering information about the client's condition. The other phases of the nursing process involve analyzing the information gathered during assessment (diagnosis), developing a plan of care (planning), carrying out interventions (implementation), and evaluating the effectiveness of care (evaluation).
Correct Answer is A
Explanation
When providing education to a postoperative client on how to use an incentive spirometer, an accurate step that should be included in the education plan is to instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose ¹⁴. This helps the client to take deep breaths and fully expand their lungs. The other options (Instruct the client to inhale normally and then place the lips securely around the mouthpiece, Encourage the client to perform incentive spirometry 2 to 3 times every 1 to 2 hours, if possible, and When the client cannot inhale anymore, the client should hold his breath and count to 10) are not accurate steps that should be included in the education plan.
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