A 17-year-old male patient presents to the Emergency Department (ED) after a skydiving accident and tells the nurse that he is very anxious, is nauseated, and feels hot. These types of data would be:

Objective Data

Introspective Data

Subjective Data

Reflective Data

Answer and Explanation

The Correct Answer is C

Choice a reason:
Objective data refers to information that is observable and measurable by the healthcare provider, such as vital signs, physical examination findings, and laboratory results. The patient's statements about his feelings are not objective data because they cannot be directly measured or observed by the nurse.

Choice b reason:
Introspective data is not a commonly used term in healthcare. Introspection generally refers to the examination of one's own conscious thoughts and feelings, which in the context of healthcare, can be part of subjective data as it is reported by the patient.

Choice c reason:
Subjective data consists of information that is reported by the patient, including feelings, perceptions, and concerns. It is called 'subjective' because it is based on the patient's personal experience and cannot be independently verified by the nurse. In this case, the patient's report of feeling anxious, nauseated, and hot is considered subjective data.

Choice d reason:
Reflective data is not a standard term in healthcare documentation. Reflection is a process of personal thought and does not pertain to the clinical data gathered during a patient assessment.

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Correct Answer is B

Explanation

Choice A Reason:
Angular cheilitis is characterized by inflammation of one or both corners of the mouth. It often presents as red, swollen patches in the corners of the mouth and can be associated with fungal or bacterial infection. However, it does not typically cause vesicular eruptions, which are more indicative of viral infections like herpes simplex.

Choice B Reason:
Herpes simplex virus (HSV) is known for causing vesicular eruptions, commonly referred to as cold sores or fever blisters, around the lips and mouth area. These eruptions are fluid-filled blisters that can be painful and are highly indicative of an HSV infection, particularly HSV type 1, which commonly affects the oral region.

Choice C Reason:
Angioedema involves the rapid swelling of the deeper layers of the skin, often seen with hives. While it can affect the lips and surrounding areas, it does not cause vesicular eruptions. Angioedema is more associated with allergic reactions and can be part of anaphylaxis, a severe systemic reaction.

A. Formal hearing test. B. Rubbing fingers test. C. Tuning fork test. D. Whisper hearing test.

Correct Answer is A

Explanation

Choice A reason:
A formal hearing test, or audiometry, is the most comprehensive method for assessing hearing loss, which can be a side effect of ototoxic medications. These tests can detect both conductive and sensorineural hearing loss, providing a detailed profile of hearing function across different frequencies. For clients receiving ototoxic antibiotics, regular monitoring through formal hearing tests is recommended to detect any early signs of hearing impairment and to implement timely interventions.
Choice B reason:
The rubbing fingers test is a rudimentary hearing screening method where the examiner rubs their fingers together near the patient's ear, asking them to indicate when they hear the sound. While this test can be used as a quick check for hearing loss, it is not as sensitive or specific as formal audiometry and may not detect early or mild hearing loss caused by ototoxic drugs.
Choice C reason:
Tuning fork tests, such as the Weber and Rinne tests, are used to differentiate between conductive and sensorineural hearing loss. These tests can be useful in a clinical setting to provide immediate information about the type of hearing loss; however, they are not as comprehensive as formal hearing tests and may not be sufficient for monitoring ototoxicity.
Choice D reason:
The whisper hearing test involves the examiner whispering words or numbers and asking the patient to repeat them. This test can be useful for detecting significant hearing loss but may not be sensitive enough to detect the early stages of ototoxicity. Moreover, the test's accuracy can be affected by the examiner's voice level and the testing environment.

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A 17-year-old male patient presents to the Emergency Department (ED) after a skydiving accident and tells the nurse that he is very anxious, is nauseated, and feels hot. These types of data would be:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. Which problem should the nurse document?

Correct Answer is B

Explanation

A client has been receiving intravenous antibiotics (ototoxic) for several weeks. Which prevention strategy would be best for the nurse to recommend for this client?

Correct Answer is A

Explanation

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply)

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