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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Heart failure is a condition in which the heart is unable to pump blood effectively, leading to a buildup of fluid in the body. This can result in edema (swelling) and fluid accumulation in the lungs, causing coarse crackles when breathing. The term for this condition is fluid volume excess, which refers to an excessive amount of fluid in the body.
Myocardial infarction is a heart attack, atelectasis is a collapse of lung tissue, and fluid volume deficit refers to a lack of fluid in the body.
Correct Answer is A
Explanation
The nurse should instruct the client to include more whole grains in their diet and drink more water daily to improve their inconsistent fecal elimination pattern. Whole grains are high in fiber which can help regulate bowel movements and drinking more water can help keep stools soft and easy to pass ¹. Using enemas as desired is not a recommended solution for long-term management of inconsistent fecal elimination patterns. It is important for the client to consult with their healthcare provider for personalized advice and treatment options.
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