Which of these assessment findings should a nurse record as subjective?
Hives.
Itching.
Vomiting.
Abdominal distension.
The Correct Answer is B
This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the
patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.
For example:
Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.
Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.
Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.
Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:
- Hives: No hives or rashes on the skin are normal.
- Vomiting: No vomiting or nausea are normal.
- Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement suggests that the client needs further teaching because haloperidol is a medication that needs to be taken regularly and consistently to prevent relapse of symptoms related to schizophrenia. Stopping the medication abruptly can cause withdrawal effects and worsen the condition.
Choice B is wrong because it shows that the client understands the potential interaction between alcohol and haloperidol, which can increase the risk of sedation, drowsiness, and low blood pressure.
Choice C is wrong because it indicates that the client has realistic expectations about the onset of action of haloperidol, which can take several days or weeks to show improvement of symptoms.
Choice D is wrong because it demonstrates that the client is aware of the possible side effect of photosensitivity caused by haloperidol, which can make the skin more prone to sunburn and damage.
Haloperidol is an antipsychotic drug that works by blocking dopamine receptors in the brain. It is used to treat symptoms such as hallucinations, delusions, paranoia, and disorganized thinking in schizophrenia and other psychotic disorders. The normal dosage range for haloperidol is 0.5 to 20 mg per day, depending on the severity of the condition and the response to treatment. Some of the common side effects of haloperidol include extrapyramidal symptoms (EPS), such as muscle stiffness, tremors, restlessness, and abnormal movements; neuroleptic malignant syndrome (NMS), which is a rare but serious condition characterized by fever, muscle rigidity, altered mental status, and autonomic instability; and tardive dyskinesia (TD), which is a chronic movement disorder that involves involuntary movements of the tongue, lips, face, and limbs. Haloperidol can also cause weight gain, dry mouth, blurred vision, constipation, dizziness, insomnia, and sexual dysfunction.
Haloperidol should be used with caution in patients with cardiovascular disease, liver disease, seizure disorder, diabetes mellitus, thyroid dysfunction
Correct Answer is B
Explanation
This is because the pH of gastric contents is acidic (less than 5.5) and can indicate that the tube is in the stomach. This method is predictive of the correct placement of a nasogastric tube.
Choice A is wrong because fluoroscopy is not the most reliable method to confirm the correct placement of a nasogastric tube. It is an imaging technique that uses X-rays to show the movement of the tube, but it is not always available or feasible.
Choice C is wrong because injecting air and listening for gurgling sounds is not a reliable method to confirm the correct placement of a nasogastric tube. It can cause false-positive results and does not differentiate between the stomach and the respiratory tract.
Choice D is wrong because observing for bubbles after placing the end of the tube in a cup of water is not a reliable method to confirm the correct placement of a nasogastric tube. It can also cause false-positive results and does not differentiate between the stomach and the respiratory tract.
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