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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 coughing.
- B. The patient has cyanosis of the lips.
- C. The patient experiences tachypnea.
- D. The patient complains of generalized discomfort.
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. Complaining of generalized discomfort is an example of subjective data. All other options are examples of objective data.
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What is the basis for designing and selecting nursing interventions to meet patient needs?
- A. Patient problem
- B. Care plan
- C. Health care provider's orders
- D. Nurse's notes
Correct Answer: A
Rationale: The patient problem is the basis for developing nursing interventions.
A clinical judgment concerning a human response to health conditions/life processes or a vulnerability for that response by an individual family group or community is known as a nursing ____
Correct Answer: diagnosis
Rationale: A patient problem is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.
Which nursing intervention is complete and correct?
- A. May 10: Unlicensed assistive personnel will ambulate patient. A. Nurse
- B. Day nurse will cleanse wound and change dressings every day. May 10 A. Nurse
- C. Unlicensed assistive personnel will serve 8 oz glass of juice at each meal 5/10.
- D. P.M. nurse will ensure that heel protectors are in place before bedtime.
Correct Answer: B
Rationale: Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention.
The document that outlines a plan for care interventions over a specified time frame is called a clinical pathway critical path action plan or caremap.
Correct Answer: multidisciplinary
Rationale: A clinical pathway is an organized multidisciplinary plan over a specified time frame, which outlines aspects of patient care. They are also called critical paths, action plans, and care maps.
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.