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A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information reported by the patient, such as their feelings, emotions, and perceptions. In this case, the patient describing excitement about discharge is an example of subjective data. The other choices (A, B, D) are objective data because they are observable and measurable by the nurse. Temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. It is important for nurses to differentiate between subjective and objective data to provide accurate assessments and care for their patients.
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A client with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
- A. Vision changes
- B. Headache
- C. Hearing loss
- D. Anorexia
Correct Answer: A
Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.
Why may an ice collar be ordered for a client who is undergoing drainage of a peritonsillar abscess?
- A. To reduce swelling and pain
- B. To prevent respiratory obstruction
- C. To help the client drink fluids
- D. To prevent excessive bleeding
Correct Answer: B
Rationale: The correct answer is B: To prevent respiratory obstruction. An ice collar is used to reduce swelling and inflammation, which can help prevent the abscess from compressing the airway and causing respiratory obstruction. This is crucial in cases of peritonsillar abscess to ensure the client's airway remains patent. Choices A, C, and D do not directly address the primary concern of preventing respiratory obstruction in this context.
The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate?
- A. Teaches proper handwashing technique
- B. Properly cleans the patient’s toilet
- C. Transports urine specimen to the lab
- D. Informs the oncoming nurse during hand-off
Correct Answer: A
Rationale: The correct answer is A: Teaches proper handwashing technique. This is the most appropriate intervention because proper handwashing can help prevent the spread of infection, including urinary infections. Teaching the patient about handwashing empowers them to take control of their own hygiene, reducing the risk of infection.
Summary of why other choices are incorrect:
B: Properly cleans the patient's toilet - While important for maintaining cleanliness, this does not directly address the patient's risk for a urinary infection.
C: Transports urine specimen to the lab - This is not a direct care intervention for preventing urinary infections.
D: Informs the oncoming nurse during hand-off - Hand-off communication is important for continuity of care but does not directly address the patient's risk for a urinary infection.
Which of the following would be the most appropriate nursing intervention when caring for a client with a fractured rib?
- A. Apply immobilization device after examination by physician
- B. Discourage taking deep breaths if breathing is painful
- C. Advise against using analgesics and regional nerve blocks
- D. Encouraged increased fluid intake if pulmonary contusion exists
Correct Answer: A
Rationale: Correct Answer: A - Apply immobilization device after examination by physician
Rationale:
1. Immobilization helps reduce pain and prevent further injury.
2. Physician examination ensures proper diagnosis and treatment plan.
3. Immobilization device may include chest binders or splints for support.
4. It is crucial to follow medical advice to prevent complications.
Summary:
B: Discouraging deep breaths can lead to respiratory complications.
C: Advising against analgesics can increase pain and hinder recovery.
D: Increased fluid intake is important but not directly related to rib fracture care.
A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.)
- A. Patient’s temperature
- B. Patient’s wound appearance
- C. Patient describing excitement about discharge
- D. Patient pacing the floor while awaiting test results
Correct Answer: C
Rationale: The correct answer is C because subjective data refers to information provided by the patient, such as their feelings, perceptions, and symptoms. In this case, the patient describing excitement about discharge is subjective as it is based on their personal experience. The other options (A, B, D) are objective data as they can be measured or observed directly without interpretation. The patient's temperature (A) and wound appearance (B) are physical observations, while the patient pacing the floor (D) is a behavior that can be observed. Therefore, only choice C fits the definition of subjective data in a nursing assessment.