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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 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.
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Mr. Aurelio diagnosed with heart failure, was prescribed with a 2 gm sodium diet. which of the following foods would nurse Norma instruct him to restrict?
- A. whole wheat bread
- B. canned tomato juice
- C. beef tenderloin strips
- D. apples
Correct Answer: B
Rationale: The correct answer is B: canned tomato juice. Canned tomato juice is high in sodium content, which would not be suitable for a patient on a 2 gm sodium diet for heart failure. Sodium restriction is crucial in managing heart failure to reduce fluid retention and strain on the heart. Whole wheat bread, beef tenderloin strips, and apples are lower in sodium content compared to canned tomato juice, making them more appropriate choices for someone on a low-sodium diet.
A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention?
- A. “Do you feel like you need to go to the bathroom?”
- B. “Are you able to walk to the bathroom by yourself?”
- C. “When was the last time you took your medicine?” NursingStoreRN
- D. “Do you have a safety rail in your bathroom at home?”
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Asking if the patient feels the need to go to the bathroom helps assess urgency.
2. Urinary retention may lead to the inability to sense the urge to void.
3. This question directly addresses the issue of voiding, crucial in diagnosing urinary retention.
Summary:
B: Mobility is not directly related to urinary retention.
C: Medication timing is important but not directly related to urinary retention.
D: Safety rail inquiry is more related to fall prevention, not urinary retention.
A 40 year old woman with aplastic anemia is prescribed estrogen with progesterone. The nurse can expect that these medications are given for which of the following reasons?
- A. To stimulate bone growth
- B. To enhance sodium and potassium
- C. To regulate fluid balance absorption
- D. To promote utilization and storage of fluids
Correct Answer: A
Rationale: The correct answer is A: To stimulate bone growth. Estrogen and progesterone are hormones that play a crucial role in maintaining bone density and promoting bone growth. In postmenopausal women or individuals with conditions like aplastic anemia, bone health can be compromised. Estrogen helps in preventing bone loss and maintaining bone strength, while progesterone also contributes to bone formation. Therefore, in this scenario, these medications are likely prescribed to help improve bone health in the woman with aplastic anemia.
Incorrect choices:
B: Estrogen and progesterone do not directly enhance sodium and potassium levels.
C: Estrogen and progesterone do not regulate fluid balance absorption directly.
D: Estrogen and progesterone do not specifically promote utilization and storage of fluids.
The kidneys regulate acid-base balance by all of the following mechanisms except:
- A. Excreting hydrogen ions (H )
- B. Reabsorbing carbon dioxide into the
- C. Reabsorbing or excreting HCO into blood
- D. retaining hydrogen ions
Correct Answer: B
Rationale: Rationale: The correct answer is B because the kidneys do not reabsorb carbon dioxide to regulate acid-base balance. Carbon dioxide is mainly regulated by the lungs through respiration. The kidneys regulate acid-base balance by excreting hydrogen ions, reabsorbing or excreting bicarbonate (HCO3-) into the blood, and retaining or excreting hydrogen ions. Reabsorbing carbon dioxide is not a mechanism utilized by the kidneys for acid-base balance. Choices A, C, and D are correct mechanisms involved in acid-base balance regulation by the kidneys.
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.