Which of these assessment findings should a nurse record as subjective?

Hives.

Itching.

Vomiting.

Abdominal distension.

Answer and Explanation

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).

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Correct Answer is C

Explanation

A two-hour postprandial glucose test is done to check your blood sugar level two hours after you eat a meal.

This test helps to diagnose diabetes or monitor its treatment. A normal blood sugar level for this test is less than 140 mg/dL.

Choice A is wrong because fasting means not eating for at least eight hours before the test. This is done for a fasting blood glucose test, not a postprandial one.

Choice B is wrong because before breakfast means before you eat anything in the morning. This is also done for a fasting blood glucose test, not a postprandial one.

Choice D is wrong because before glucose is consumed means before you drink a sugary liquid for a glucose tolerance test. This test measures how your body handles glucose after drinking it, not after eating a meal.

A. Anxiety. B. Acute pain. C. Knowledge deficit. D. Nausea and vomiting.

Correct Answer is B

Explanation

This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.

Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.

Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.

Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.

Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.

Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.

Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.

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Which of these assessment findings should a nurse record as subjective?

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Naxlex Comprehensive Predictor Exams

A client is to have a two-hour post-prandial blood glucose drawn. Which statement should the nurse make to inform the client when the two-hour test will be performed?

Correct Answer is C

Explanation

A client admitted to the coronary care unit with an inferior wall myocardial infarction is anxious, sweating, tachypneic, and reports midsternal chest discomfort and nausea. Which nursing diagnosis is the priority?

Correct Answer is B

Explanation

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