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

To focus on aﬀective learning with this client, the nurse should explore the client's feelings about dietary modifications. Aﬀective learning involves the development of values, attitudes, and emotions. By exploring the client's feelings about dietary modifications, the nurse can help the client understand and accept the changes that are necessary for managing their condition.

A. Document that the potential problem is being prevented from recurring. B. Document that the problem has been resolved and the goal has been met. C. Assume that whatever the cause was, the symptoms may return, but the goal was met. D. Keep the problem on the care plan in case the symptoms return.

Correct Answer is B

Explanation

The nursing diagnosis was "Risk for Deficient Fluid Volume" related to excessive ﬂuid loss, secondary to diarrhea and vomiting. The goal was set that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week and has had no diarrhea or vomiting for the past 5 days, indicating that the problem has been resolved. Therefore, the nurse should document that the problem has been resolved and the goal has been met.

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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

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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