Nokea
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 based on their feelings, perceptions, and experiences. In this case, the patient describing excitement about discharge is subjective data as it reflects the patient's emotional state. The other choices, A, B, and D, are considered objective data because they are observable and measurable by the nurse. The patient's temperature can be measured (A), the wound appearance can be visually assessed (B), and the patient pacing the floor is an observable behavior (D). Therefore, these choices are not subjective data.
You may also like to solve these questions
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 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: Subjective data are information reported by the patient that cannot be observed or measured by others. In this case, choice C is correct because the patient describing excitement about discharge is personal and based on the patient's feelings or perceptions. This is subjective data because it is based on the patient's own experiences and emotions. Choices A and B are incorrect because patient's temperature and wound appearance are objective data that can be measured or observed by the nurse. Choice D is also incorrect as patient pacing the floor is an observable behavior, making it objective data. Therefore, choice C is the correct answer as it represents subjective data in the context of the assessment.
A nurse approaches a hospitalized poststroke patient from the patient’s left side to do an assessment. The patient is staring straight ahead, and does not respond to the nurse’s presence or voice. Which action should the nurse take first?
- A. Walk to the other side of the bed and try again
- B. Speak more loudly and clearly
- C. Wave his or her fingers in front of the patient’s face
- D. Use a picture to explain to the patient what the nurse is going to do.
Correct Answer: A
Rationale: Rationale:
1. By approaching the patient from the other side, the nurse can assess if the patient has a visual field deficit.
2. This step helps determine if the lack of response is due to a sensory issue.
3. It allows the nurse to rule out unilateral neglect or hemianopsia.
4. Walking to the other side is a basic assessment technique to evaluate visual and sensory deficits in poststroke patients.
Other Choices:
B. Speaking more loudly and clearly may not address the potential sensory issues the patient is experiencing.
C. Waving fingers in front of the patient's face does not provide a comprehensive assessment of visual field deficits.
D. Using a picture may be helpful, but addressing the potential visual field deficit should be prioritized first.
There seems to be a positive correlation between type 2 diabetes mellitus and:
- A. Hypotension
- B. Obesity
- C. Kidney dysfunction
- D. Sex
Correct Answer: B
Rationale: The correct answer is B: Obesity. Obesity is a well-established risk factor for developing type 2 diabetes mellitus due to the increased resistance of body cells to insulin. This leads to elevated blood sugar levels. Hypotension (A) is low blood pressure and is not typically associated with type 2 diabetes. Kidney dysfunction (C) is a complication of diabetes but not a direct correlation. Sex (D) does not have a direct link to the development of type 2 diabetes. Therefore, the most likely correlation is with obesity due to its impact on insulin resistance.
A client is scheduled to receive methotrexate (Folex), 0.625 mg/kg P.O. daily, to treat malignant lymphoma. Before administering the drug, the nurse reviews the client’s medication history. Which of the following drugs might interact with methotrexate?
- A. digoxin (Lanoxin)
- B. Probenecid (Benemid)
- C. theophylline (Slo-Phyllin)
- D. Famotidine (Pepcid)
Correct Answer: B
Rationale: The correct answer is B: Probenecid (Benemid). Probenecid can increase methotrexate levels, leading to potential toxicity. Methotrexate is primarily eliminated by the kidneys, and Probenecid inhibits renal tubular secretion, causing methotrexate levels to rise. Digoxin (A), theophylline (C), and famotidine (D) do not have significant interactions with methotrexate. In summary, Probenecid is the correct answer as it can increase methotrexate levels through renal tubular secretion inhibition, while the other choices do not have a significant interaction with methotrexate.