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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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

Choice a reason:
Obtaining and checking the needed equipment is essential before conducting a physical examination. This ensures that all necessary tools are functional and readily available, which facilitates a smooth and efficient assessment process. It also minimizes interruptions that could cause discomfort or anxiety for the client.
Choice b reason:
While turning on relaxing music of the client's choice may create a calming environment, it is not a standard procedure before a physical examination. Music preferences are subjective, and what is relaxing for one person may be distracting for another. Additionally, music could interfere with the ability to hear heart, lung, or bowel sounds during auscultation.
Choice c reason:
Identifying ways to ensure client privacy is a fundamental nursing responsibility. It respects the client's dignity and promotes a sense of safety and comfort. Privacy can be ensured by closing curtains, securing the area, and making sure the examination is conducted in a private setting.
Choice d reason:
Washing hands is a critical step before any physical examination. It is a primary measure for infection control, protecting both the nurse and the client from potential transmission of microorganisms.
Choice e reason:
Dimming the lighting to promote comfort is not typically recommended before a physical examination. Adequate lighting is crucial for the inspection phase of the examination, allowing the nurse to observe the client's general appearance, skin color, and other physical characteristics accurately.

A. Exophthalmos B. Photophobia C. Weight loss D. Lethargy

Correct Answer is D

Explanation

Choice a reason:
Exophthalmos, or protrusion of the eyeballs, is not a typical finding in hypothyroidism. It is more commonly associated with hyperthyroidism, particularly Graves' disease, which is characterized by an overactive thyroid gland.

Choice b reason:
Photophobia, or light sensitivity, is not a common symptom of hypothyroidism. While it can be associated with other conditions, it is not directly related to the function of the thyroid gland.

Choice c reason:
Weight loss is typically not associated with hypothyroidism. In fact, individuals with hypothyroidism often experience weight gain due to a slowed metabolism, which is the opposite of weight loss.

Choice d reason:
Lethargy is a common symptom of hypothyroidism. The condition can lead to a decrease in thyroid hormone production, which can slow down the body's metabolism, resulting in feelings of fatigue, sluggishness, and lethargy.

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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

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

Correct Answer is ["A","C","D"]

Explanation

A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

The student nurse is reviewing different types of health history. Which client situation would require an Emergency health history?

While examining a client, the nurse observes the client's chest to be barrel-shaped. The nurse would interpret this as indicating which of the following?

During an assessment of the ear structures, the nurse would expect to identify which structure as part of the middle ear?

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

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?

A nurse is performing a respiratory system physical examination. To assess the resonance of voice sounds heard during auscultation of the lungs, the nurse instructs the patient to say "ee," and if the sound is heard as "ay," this is known as: