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 A

Explanation

A stage II pressure ulcer is a wound that presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. This type of wound is caused by unrelieved pressure on the skin, resulting in damage to the underlying tissue. In this scenario, the nurse notes an area of tissue injury on the client's sacral area that matches the description of a stage II pressure ulcer. Stage I pressure ulcers are characterized by non-blanchable erythema of intact skin, while stage III and IV pressure ulcers involve full-thickness tissue loss and may expose underlying muscle, bone, or other structures.

A. Instruct the client to report promptly to the practitioner any decreased redness, swelling, pain, or discharge from the incision or drain sites. B. Emphasize the importance of adequate rest for healing and immune function. C. Instruct the client to use pain medications as ordered and not to exceed the prescribed dose. D. Teach the client to avoid using alcohol or other central narcotic analgesics.

Correct Answer is A

Explanation

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. This includes instructing the client to report promptly to the practitioner any **increased** redness, swelling, pain, or discharge from the incision or drain sites. These symptoms may indicate an infection or other complication that requires medical attention. The other actions listed are correct and important for promoting healing and wellness after discharge.

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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

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. What is the correct name of this wound?

Correct Answer is A

Explanation

During discharge planning, the nurse is responsible for teaching the client how to maintain comfort, promote healing, and restore wellness. However, one of the actions listed below is not correct.

Correct Answer is A

Explanation

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?

A client has a history of an inconsistent fecal elimination pattern. What should the nurse instruct this client to improve this health problem?

The nurse is admitting a new client to the unit. The nurse notes that this client would need an alternate meal choice when the menu specified pork for a meal. Members of which cultural group might request an alternative meal choice?

Which of the following is marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnoea?

While in the dining room at the hospital, the nurse notes a visitor has forceful coughs. Which actions would the nurse take to assist this visitor? Select all that apply:

How would a nurse document the condition in which a client has a normal state of awareness?

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