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When assessing a client, the nurse should establish which finding(s) as objective? (Select all that apply.).

A.

Urticaria.

B.

Hypertension.

C.

Diaphoresis.

D.

Nausea.

E.

Anxiety.

F.

Edema.

Answer and Explanation

Correct Answer : A,B,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.


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Related Questions

Correct Answer is B

Explanation

Choice A rationale:

Assisting in discharging stable clients to home is not the most appropriate assignment when a mass casualty event has occurred. During such events, resources are needed for critically injured patients, and stable clients can typically be discharged by non-emergency staff.

Choice B rationale:

Determining the acuity and number of casualties arriving at the facility is the most appropriate assignment during a mass casualty event. This information is critical for allocating resources and providing the necessary level of care to those affected.

Choice C rationale:

Delegating tasks to emergency healthcare specialists may be necessary, but it is not the initial assignment for the nurse working on a medical-surgical unit. Assessing the situation and determining the acuity of incoming casualties take precedence.

Choice D rationale:

Providing informational updates to members of the media is not the role of a nurse during a mass casualty event. This task should be handled by hospital public relations or designated spokespersons to ensure accurate and controlled information dissemination.

Correct Answer is C

Explanation

The correct answer is choicec. Administer prescribed stool softener.

Choice A rationale:

Administering prescribed PRN sleep medications can help the client rest, but it is not the highest priority. Managing pain and preventing complications from the laceration are more critical.

Choice B rationale:

Encouraging the use of prescribed analgesic perineal sprays can help manage pain and promote healing, but it is not as crucial as preventing constipation, which can cause significant discomfort and complications.

Choice C rationale:

Administering prescribed stool softeners is the highest priority because a fourth-degree laceration involves the anal sphincter and rectal mucosa.Preventing constipation is essential to avoid straining during bowel movements, which can cause pain and disrupt the healing process.

Choice D rationale:

Encouraging breastfeeding to promote uterine involution is important for postpartum recovery, but it is not directly related to the care of a fourth-degree laceration. Managing pain and preventing complications from the laceration take precedence.

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