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During an admission assessment the nurse collects objective and subjective data. What is an example of subjective data?
- A. The patient is asleep.
- B. The patient is tearful.
- C. The patient has facial grimacing.
- D. The patient states "I hurt all over."
Correct Answer: D
Rationale: Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Stating 'I hurt all over' is an example of subjective data. All other options are examples of objective data.
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What assists the nurse in the identification of patient problems?
- A. Objective data
- B. Subjective data
- C. Data clustering
- D. Validated data
Correct Answer: C
Rationale: Data clustering assists the nurse in determining patient problems.
What is an appropriate outcome statement for a patient with a patient problem of ineffective airway clearance related to thick secretions?
- A. The patient will increase intake to 1000 mL daily to liquefy secretions.
- B. The patient will cough more frequently within 3 days.
- C. The patient will breathe better within 3 days.
- D. The patient will perform deep-breathing exercises four times daily.
Correct Answer: A
Rationale: The patient goal would be to improve airway clearance. Coughing more frequently within 3 days and performing deep-breathing exercises four times daily do not directly relate to the problem of thick secretions. Breathing better within 3 days is too vague.
Which are considered phases of the nursing process?
- A. Diagnosis
- B. Prediction
- C. Assessment
- D. Evaluation
- E. Implementation
- F. Outcome identification
Correct Answer: A,C,D,E,F
Rationale: The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process.
What is an important consideration when developing the care plan?
- A. Ensure the number of interventions is limited.
- B. Ensure the patient is involved in the process.
- C. Ensure interventions will be easy to implement.
- D. Ensure evaluation of the patient problems is possible.
Correct Answer: B
Rationale: Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nor do they have to be easy. The patient problems are not evaluated; the patient's progress toward the outcome is.
During a physical examination the nurse discovers that the patient demonstrates signs of flushed dry hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent?
- A. Symptoms
- B. Data clustering
- C. Signs of fluid overload
- D. Urinary retention
Correct Answer: B
Rationale: The nurse organizes data, and those that are related are referred to as clustering. These are also signs of fluid overload.