When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).
Urticaria.
Hypertension.
Diaphoresis.
Nausea.
Anxiety.
Edema.
Correct Answer : A,C,F
Choice A rationale:
Urticaria is a skin condition characterized by the sudden appearance of raised, itchy, and red welts on the skin. It is an objective finding because it can be observed and assessed visually. The presence of urticaria may indicate an allergic reaction or another underlying condition.
Choice B rationale:
Hypertension is a subjective finding because it cannot be directly observed. It requires blood pressure measurement to confirm, making it a subjective parameter.
Choice C rationale:
Diaphoresis refers to excessive sweating, which can be observed and assessed visually. It is an objective finding and may be indicative of various conditions, including anxiety or fever.
Choice D rationale:
Nausea is a subjective symptom because it is a sensation that the client experiences and reports. It cannot be directly observed by the nurse, making it a subjective parameter.
Choice E rationale:
Anxiety is a subjective symptom, as it is a mental and emotional state experienced by the client. It cannot be directly observed, making it a subjective parameter.
Choice F rationale:
Edema is an objective finding because it can be visually assessed by the nurse. Edema is the accumulation of excess fluid in body tissues, and its presence or absence can be objectively determined.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is d. hypovolemic.
Choice A reason: This is not a good choice. Septic shock is a type of distributive shock that occurs when an infection causes a systemic inflammatory response that leads to vasodilation, hypotension, and organ dysfunction. Septic shock is not the most common type of shock in children, although it can be a serious and life-threatening condition.
Choice B reason: This is not a good choice. Anaphylactic shock is a type of distributive shock that occurs when an allergic reaction causes a severe and rapid hypersensitivity response that leads to bronchoconstriction, angioedema, and hypotension. Anaphylactic shock is not the most common type of shock in children, although it can be a medical emergency that requires immediate treatment.
Choice C reason: This is not a good choice. Distributive shock is a broad category of shock that occurs when there is a loss of vascular tone and blood volume distribution that leads to hypoperfusion and tissue hypoxia. Distributive shock can be caused by various factors, such as sepsis, anaphylaxis, neurogenic injury, or adrenal insufficiency. Distributive shock is not the most common type of shock in children, although it can be a complex and challenging condition to manage.
Choice D reason: This is the correct choice. Hypovolemic shock is the most common type of shock in children. Hypovolemic shock occurs when there is a loss of blood or fluid volume that leads to decreased preload, cardiac output, and blood pressure. Hypovolemic shock can be caused by various factors, such as hemorrhage, dehydration, vomiting, diarrhea, or burns. Hypovolemic shock can be a life-threatening condition that requires prompt fluid resuscitation and correction of the underlying cause.
Correct Answer is D
Explanation
Choice D rationale:
Taking zolpidem before bedtime is the correct information to include in the education. Zolpidem is a medication used for the short-term treatment of insomnia and should be taken immediately before going to bed to facilitate sleep onset.
Choice A rationale:
Crushing zolpidem to increase absorption is not recommended. The medication should be taken whole and not crushed or chewed.
Choice B rationale:
Storing zolpidem at room temperature is correct. Like many medications, zolpidem should be stored at a controlled room temperature, away from moisture and heat.
Choice C rationale:
Administering zolpidem with a meal is not necessary and may delay the onset of its effects. It is typically taken on an empty stomach for faster absorption.
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