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During an admission assessment the nurse collects objective and subjective data. What is an example of objective data?
- A. The patient is jaundiced.
- B. The patient states "I am nervous."
- C. The patient complains of palpitations.
- D. The patient denies dizziness when ambulating.
Correct Answer: A
Rationale: Objective data are observable and measurable signs. Objective data can be recorded. A camera can record a rash, a skin lesion, or puffy eyes. A tape recorder can give evidence of crying or slurred speech. A thermometer can record a temperature elevation. Other terms for objective data are signs and objective cues. The patient is jaundiced is an example of objective data. All other options are examples of subjective data.
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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 complains of nausea.
- B. The patient is vomiting.
- C. The patient experiences tachycardia.
- D. The patient is pacing the halls.
Correct Answer: A
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 nausea is an example of subjective data. All other options are examples of objective data.
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.
A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date it is determined that what has occurred?
- A. Omission
- B. Variance
- C. Failure
- D. Error
Correct Answer: B
Rationale: A variance occurs when a projected outcome is not met.
NANDA International meets to reorganize diagnosis labels and language every 2 ____
Correct Answer: years
Rationale: NANDA International meets every two years to revise language, form, and diagnosis labels.
Who is the person responsible for analyzing and interpreting data to arrive at a patient problem?
- A. Health care provider
- B. LPN/LVN
- C. RN
- D. Technician
Correct Answer: C
Rationale: The RN is responsible for analyzing and interpreting data.