Nokea
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: Objective data are measurable and observable facts. Respirations (C) of 16 per minute is objective data as it is a quantifiable measurement that can be counted and recorded. It is not influenced by personal interpretation or bias. Choices A, B, and D are subjective data as they rely on the patient's feelings, perceptions, or symptoms, which can vary and are open to interpretation. Therefore, choice C is the correct answer as it represents concrete, verifiable information that can be used in the patient's assessment and care planning.
You may also like to solve these questions
If Mr. Franco’s Right side is weak, What should be the most accurate analysis by the nurse?
- A. Expressive aphasia is prominent on clients with right sided weakness
- B. The affected lobe in the patient is the Right lobe
- C. The client will have problems in judging distance and proprioception
- D. Clients orientation to time and space will be much affected NEUROLOGIC NURSING Situation: A computer analyst, Mr. Ricardo J. Santos, 25 was brought to the hospital for diagnostic workup after he had experienced seizure in his office.
Correct Answer: B
Rationale: The correct answer is B because right-sided weakness is typically associated with damage or impairment in the left lobe of the brain. The brain controls the opposite side of the body, so weakness on the right side indicates left brain involvement. This is known as contralateral control. The other choices are incorrect because expressive aphasia is associated with left brain damage, problems in judging distance and proprioception are related to parietal lobe damage, and orientation to time and space is more related to frontal lobe damage. Therefore, the most accurate analysis by the nurse would be to consider the affected lobe as the right lobe in this case.
Which of the ff factors predisposes a client to the development of TB?
- A. Exposure to toxic gases
- B. Congenital abnormalities
- C. Obstruction by tumor
- D. Malnutrition
Correct Answer: D
Rationale: The correct answer is D: Malnutrition. Malnutrition weakens the immune system, making individuals more susceptible to contracting tuberculosis. A well-nourished individual has a stronger immune response to fight off TB bacteria. Exposure to toxic gases (A), congenital abnormalities (B), and obstruction by tumor (C) do not directly predispose a client to TB. Malnutrition is the key factor as it impairs the immune system's ability to combat the TB bacteria effectively.
Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
- A. Perform dressing changes twice a day as ordered.
- B. Teach the patient about signs and symptoms of infection.
- C. Instruct the family about how to perform dressing changes.
- D. Gently refocus patient from discussing body image changes.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Dressing changes twice a day help maintain a clean wound environment, reducing the risk of infection.
2. Regular dressing changes promote proper wound healing by facilitating moisture balance and removal of dead tissue.
3. It is a direct intervention that addresses the patient's poor wound healing.
4. Teaching the patient about signs of infection (B) is important but does not directly address the wound healing process.
5. Instructing the family on dressing changes (C) is helpful but should not substitute direct patient care.
6. Refocusing the patient from body image changes (D) is not directly related to improving wound healing.
Which information indicates a nurse has a good understanding of a goal? It is a statement describing the patient’s accomplishments without a time
- A. restriction.
- B. It is a realistic statement predicting any negative responses to treatments.
- C. It is a broad statement describing a desired change in a patient’s behavior.
- D. It is a measurable change in a patient’s physical state.
Correct Answer: D
Rationale: Step 1: A goal should be measurable to track progress effectively.
Step 2: The statement "a measurable change in a patient's physical state" indicates a specific and quantifiable outcome.
Step 3: This aligns with the SMART criteria for goal setting - Specific, Measurable, Achievable, Relevant, Time-bound.
Step 4: Other choices lack the specificity and measurability required for a clear goal.
Step 5: Choice A talks about restriction, which is not directly related to understanding a goal.
Step 6: Choice B focuses on negative responses, which is not necessarily indicative of understanding the goal.
Step 7: Choice C is vague and lacks the specificity of a measurable outcome.
The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
- A. Increased total serum complement levels
- B. An above-normal anti-deoxyribonucleic
- C. Negative antinuclear antibody test acid
- D. Negative lupus erythematosus cell test
Correct Answer: B
Rationale: The correct answer is B: An above-normal anti-deoxyribonucleic acid. In SLE, the body produces antibodies against its own DNA, leading to the presence of anti-dsDNA antibodies. Elevated levels of anti-dsDNA antibodies are specific to SLE, confirming the diagnosis.
A: Increased total serum complement levels are seen in SLE due to complement activation but are not specific to SLE.
C: Negative antinuclear antibody test is not consistent with SLE, as ANA positivity is common in SLE.
D: Negative lupus erythematosus cell test is not specific to SLE as lupus erythematosus cells are not always present.