A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

Petechiae

Blood pressure

Nausea

Cyanosis

Answer and Explanation

The Correct Answer is C

A: Petechiae are small red or purple spots on the body, caused by minor bleeding from broken capillary blood vessels. This is an objective finding that can be observed and measured by the nurse.

B: Blood pressure is an objective measurement that can be quantified using a sphygmomanometer. It provides numerical data about the patient’s cardiovascular status.

C: Nausea is a subjective symptom reported by the patient. It reflects the patient’s personal experience and cannot be directly observed or measured by the nurse. Subjective data are crucial for understanding the patient’s perspective and symptoms.

D: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is an objective finding that can be observed by the nurse.

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Correct Answer is C

Explanation

A: A trochanter roll is used to prevent external rotation of the hips, not to prevent plantar flexion contractures.

B: A sheepskin heel pad provides cushioning and helps prevent pressure ulcers on the heels but does not prevent plantar flexion contractures.

C: A footboard is used to prevent plantar flexion contractures by keeping the feet in a neutral position. This helps maintain proper alignment and prevents the muscles and tendons from shortening.

D: An abduction pillow is used to maintain hip abduction, typically after hip surgery, and does not prevent plantar flexion contractures.

A. Place the client supine with knees bent. B. Raise the head of the client’s bed 15 to 20 degrees. C. Assess the client for manifestations of shock. D. Cover the area with a sterile dressing moistened with 0.9% sodium chloride irrigation.

Correct Answer is D

Explanation

A: Placing the client supine with knees bent can help reduce strain on the abdominal area but is not the immediate first action.

B: Raising the head of the client’s bed 15 to 20 degrees is not the priority action in this situation.

C: Assessing the client for manifestations of shock is important but should follow the immediate action of protecting the eviscerated wound.

D: Covering the area with a sterile dressing moistened with 0.9% sodium chloride irrigation is the correct first action. This helps protect the exposed organs and tissues from contamination and keeps them moist until surgical intervention can be performed.

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A nurse is completing a client history and physical examination. Which of the following information should the nurse consider subjective data?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

Correct Answer is C

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Correct Answer is D

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