Nokea
During a pre-op assessment, the nurse would chart which finding(s) as subjective data? Select all that apply.
- A. The client is sweating and wringing his hands.
- B. The client states, 'I am having second thoughts about my surgery.'
- C. The client reports he has lost 6 pounds in the last 2 months.
- D. The client's blood pressure is 128/82.
- E. The client rates his pain as a 3 on a scale of 0-10.
Correct Answer: B,C,E
Rationale: Subjective data are client-reported, including statements about surgery concerns, weight loss, and pain ratings. Sweating/wringing hands and blood pressure are objective (observable/measurable).
You may also like to solve these questions
Which activity is suitable for a client who suffered an uncomplicated myocardial infarction (MI) 2 days ago?
- A. Sitting in the bedside chair for 15 minutes three times a day
- B. Remaining on strict bed rest with bedside commode privileges
- C. Ambulating in the room and hall as tolerated
- D. Sitting on the bedside for 5 minutes three times a day with assistance
Correct Answer: A
Rationale: Sitting in a chair for short periods is appropriate 2 days post-MI to promote circulation and prevent complications, while ambulation is too strenuous.
The nurse who is caring for a client with cancer notes a WBC of 500 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?
- A. Assess temperature every 4 hours because of risk for hypothermia
- B. Instruct the client to avoid large crowds and people who are sick
- C. Instruct in the use of a soft toothbrush
- D. Assess for hematuria
Correct Answer: B
Rationale: A WBC of 500 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people is critical to prevent infections. The other interventions are less specific.
A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?
- A. I keep having recurring nightmares.
- B. I have a headache and my vision is blurry.
- C. I feel like I'm watching myself from outside my body.
- D. I hear voices telling me what to do.
Correct Answer: C
Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.
The nursing assistant reports to the nurse that a client who is one-day postoperative after an angioplasty is refusing to eat and states, 'I just don't feel good.' Which of the following actions, if taken by the nurse, is BEST?
- A. The nurse talks with the client about how he is feeling.
- B. The nurse instructs the nursing assistant to sit with the client while he eats.
- C. The nurse contacts the physician to obtain an order for an antacid.
- D. The nurse evaluates the most recent vital signs recorded in the chart.
Correct Answer: A
Rationale: assessment required; monitor for closure of vessel, bleeding, hypotension, dysrhythmias
The nurse is caring for a client receiving TPN. The nurse understands that TPN management includes which of the following? Select all that apply.
- A. monitor daily weights and intake and output
- B. monitor serum electrolytes and glucose levels daily
- C. change IV tubing every 48 hours or per facility protocol
- D. change the IV site dressing every 24 hours or per facility protocol
- E. if TPN is unavailable, OK to give D10W or D20W until TPN becomes available
Correct Answer: A, B, C
Rationale: Monitoring weights, intake/output, electrolytes, glucose, and changing tubing per protocol are standard TPN management practices. Dressings are typically changed every 7 days or per protocol, and D10W/D20W are not suitable substitutes for TPN.