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The nurse working in the mental health unit is collecting data on a newly admitted client. Which data is a primary type of subjective data collection?
- A. Client complains of a headache.
- B. Client's blood pressure is 145/88.
- C. Family member states that the client got into a fight.
- D. Police officer reports that a disturbance was created by the client.
Correct Answer: A
Rationale: Assessments are conducted by many professionals, including nurses, psychiatrists, social workers, dietitians, and other therapists. Subjective data include information that can be described or verified only by the client or family. The primary source of data is the client. Objective data can be observed or measured. Secondary sources of data may need to be collected if the client is experiencing psychosis, muteness, or catatonia. These sources of data include family, friends, neighbors, police officers, health care workers, and medical records.
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The nurse working in a long-term care setting attended a workshop on creating a restraint-free environment for the residents. When several coworkers firmly resist changing stating that their current methods are satisfactory, which action should aid the nurse in being effective in facilitating change?
- A. Pointing out to coworkers the various mistakes that they are presently making in adhering to outdated restraint procedures
- B. Informing the nursing supervisor that current restraint policies must be changed and requesting that all staff be required to comply
- C. Writing a new restraint policy over the weekend and distributing it to coworkers for immediate implementation on Monday morning
- D. Asking coworkers to help gather data comparing the facility's restraint procedures and outcomes with those of others using revised procedures
Correct Answer: D
Rationale: To be an effective change agent, the nurse must work collaboratively with others to solve common problems. The nurse who works collaboratively with others to facilitate change has a much greater chance of success than one who unilaterally demands or implements change. By enlisting the assistance of others, there is a greater chance that they will support proposed changes in procedures. To focus on errors (perceived or real) serves only to alienate others and is not effective in promoting change. A punitive atmosphere is not effective in promoting change because it discourages people from taking risks.
You are the registered nurse in a multi ethnic community health department clinic. In this role you are asked to identify clients who have genetic risk factors related to ethnicity in order to screen them for some commonly occurring diseases and disorders. You would identify a client who is of:
- A. Mediterranean ethnicity for cystic fibrosis.
- B. African American ethnicity for Tay Sachs disease.
- C. British Isles ethnicity for psychiatric mental health disorders.
- D. Saudi Arabian ethnicity for sickle cell anemia.
Correct Answer: D
Rationale: Sickle cell anemia is strongly associated with populations from regions like Saudi Arabia, Africa, and parts of India. Screening clients of Saudi Arabian ethnicity for sickle cell anemia is appropriate due to the higher prevalence of the sickle cell trait in these populations.
A client with a history of rheumatoid arthritis is prescribed hydroxychloroquine (Plaquenil). The nurse should instruct the client to:
- A. Have regular eye exams.
- B. Take the medication on an empty stomach.
- C. Avoid calcium-rich foods.
- D. Stop the medication if joint pain resolves.
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams.
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?
- A. Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.
- B. Ask the client to assume a side-lying position with the knees flexed.
- C. Perform massage vigorously at the level of the umbilicus if the fundus feels boggy.
- D. Place the client on a bedpan in case the uterine palpation stimulates the client to void.
Correct Answer: A
Rationale: This technique stabilizes the uterus during fundus assessment, preventing discomfort and ensuring accurate palpation.
When a client has a tearing of tissue with irregular wound edges, the nurse should document this as:
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Colonization
Correct Answer: C
Rationale: A laceration is characterized by tearing of tissue with irregular wound edges. Contusions are bruises, abrasions are superficial, and colonization refers to bacterial presence, not wound type.