Nokea
A nurse assisting with data collection of a client gathers both subjective and objective data. Which finding would the nurse document as subjective data?
- A. The client appears anxious.
- B. Blood pressure is 170/80 mm Hg.
- C. The client states that he has a rash.
- D. The client has diminished reflexes in the legs.
Correct Answer: C
Rationale: Subjective data are information provided by the client about their symptoms, feelings, or experiences. In this case, the client reporting having a rash is subjective data because it is based on what the client says. Choices A, B, and D involve observations or measurements made by the nurse (anxious appearance, blood pressure, reflexes), which fall under objective data. Objective data are observable and measurable data obtained through physical examination, vital signs assessment, and laboratory tests.
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A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self-Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct Answer: B
Rationale: The correct answer is 'Body Image Disturbance.' The client's statement reflects concerns about self-identity and completeness related to infertility, indicating a disturbance in body image perception. 'Risk for Self-Harm' is not the best choice as there is no indication of immediate self-harm. 'Ineffective Role Performance' is less appropriate since the statement does not directly relate to a disruption in the parent's role. 'Powerlessness' could be considered if the client expressed feelings of powerlessness specifically related to the infertility issue.
The LPN is taking care of a client who is on Phenelzine (Nardil) for depression. Which meal would the nurse encourage the client to avoid?
- A. steak and potatoes
- B. prosciutto and cheese plate
- C. orange juice and toast
- D. carbonated water, shrimp and rice
Correct Answer: B
Rationale: The correct answer is 'prosciutto and cheese plate.' Phenelzine (Nardil) is an MAOI (Monoamine Oxidase Inhibitor), and clients on these drugs should avoid foods high in tyramine due to the risk of dangerous elevations in blood pressure. Prosciutto and aged cheeses are examples of foods rich in tyramine, so they should be avoided. Choices A, C, and D do not contain high levels of tyramine and are considered safe to consume while on Phenelzine.
A client, age 28, is 8 1/2 months pregnant. She is most likely to display which normal skin-color variation?
- A. vitiligo
- B. erythema
- C. cyanosis
- D. chloasma
Correct Answer: D
Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes during pregnancy. Vitiligo is characterized by depigmented patches, erythema is redness of the skin due to increased blood flow, and cyanosis is a bluish discoloration due to poor circulation or lack of oxygen, none of which are typical skin-color variations during pregnancy. Therefore, in a pregnant client, the most likely normal skin-color variation to be displayed is chloasma.
When assessing a client with deep pitting edema, with the indentation remaining for a short time and visible leg swelling, how should a nurse document this finding?
- A. 1+ edema
- B. 2+ edema
- C. 3+ edema
- D. 4+ edema
Correct Answer: C
Rationale: The correct answer is 3+ edema. When assessing for edema, the nurse presses thumbs against the ankle malleolus or the tibia. If the skin retains an indentation, it indicates pitting edema. The grading scale for pitting edema includes: 1+ for mild pitting with slight indentation and no perceptible leg swelling, 2+ for moderate pitting where the indentation subsides rapidly, 3+ for deep pitting with an indentation remaining briefly and visible leg swelling, and 4+ for very deep pitting with a long-lasting indentation and significant leg swelling. Choices A, B, and D do not accurately represent the severity of the edema described in the scenario.
A day care center has asked the nurse to provide education for parents regarding safety in the home. What type of preventive care does this represent?
- A. Primary
- B. Secondary
- C. Tertiary
- D. Health promotion
Correct Answer: A
Rationale: Primary prevention involves activities that promote wellness or prevent illness or injury. Educating parents about safety measures in the home aims to prevent injuries, making it a primary prevention strategy. Secondary prevention focuses on early detection and intervention in diseases or injuries. Tertiary prevention involves reducing disability and promoting optimal functioning in relation to a disease or injury. Health promotion encompasses activities that enhance a client's overall health and well-being. In this scenario, educating parents about safety in the home falls under primary prevention as it aims to prevent injuries before they occur.