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

Urticaria.

Hypertension.

Diaphoresis.

Nausea.

Anxiety.

Edema.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is D. Activate the lockdown procedure.

Choice A rationale:

Asking the mother about expected visitors is important for later investigation, but it does not address the immediate concern of a potentially missing infant and delays necessary security measures.

Choice B rationale:

Matching ID bands is an essential step in verifying the identity of infants and mothers, but it should follow initial actions to secure the area and prevent possible abduction.

Choice C rationale:

Determining if the newborn is in the nursery is a logical step but not the first priority. The immediate action should be to secure the unit to prevent any potential abductor from leaving.

Choice D rationale:

Activating the lockdown procedure is the first priority to ensure the safety of the infant and prevent any unauthorized individuals from leaving the facility. This step is crucial to quickly address the situation and prevent potential abduction.

A. Granulating tissue in foot ulcer. B. Reduced level of pain. C. Improved visual acuity. D. Full volume of pedal pulses. E. Full volume of pedal pulses.

Correct Answer is B

Explanation

Choice A rationale:

Granulating tissue in a foot ulcer is a positive sign of wound healing, but it may not be directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. The primary goal of pregabalin in this context is to reduce pain and neuropathic symptoms.

Choice B rationale:

A reduced level of pain is the most relevant indicator of the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin is an antiepileptic medication used to manage neuropathic pain. A decrease in pain indicates that the medication is effectively managing the client's symptoms.

Choice C rationale:

Improved visual acuity is not directly related to the effectiveness of pregabalin in treating diabetic peripheral neuropathy. Pregabalin primarily targets neuropathic pain and sensory symptoms, not visual function.

Choice D rationale:

A full volume of pedal pulses is a positive sign of adequate circulation in the lower extremities, but it may not be directly related to the effectiveness of pregabalin in treating neuropathy symptoms. The primary goal of pregabalin in this context is pain management.

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

Nursing Test Bank

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