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 B
Explanation
The first action the nurse should take in this situation is to rescue the client from immediate danger. This means ensuring that the client is safely removed from the room and away from the fire. The safety of the client is the top priority in this situation. Once the client is safe, the nurse can then take further actions such as activating the fire alarm system and attempting to extinguish the fire if possible.
Correct Answer is B
Explanation
According to Kubler-Ross's stages of grieving, denial is the first stage. It is a defense mechanism that helps individuals cope with the overwhelming emotions associated with loss. In this case, the client is refusing to believe that the loss of her husband is happening and is likely experiencing denial as a way to cope with her grief
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