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 A

Explanation

A: Cleaning hearing aids with alcohol wipes is not recommended as it can damage the devices. The client should use a soft, dry cloth or a cleaning tool designed for hearing aids.

B: Expecting the hearing aids to whistle when cupping a hand over them is normal. This feedback occurs due to the sound being reflected back into the microphone.

C: Not using hairspray while wearing hearing aids is correct. Hairspray can clog the microphone and other components of the hearing aids.

D: Changing the batteries once a week is a reasonable practice, depending on the usage and type of hearing aids. This statement does not indicate a need for further instruction.

A. Passage of flatus B. Request for a cup of tea and some toast C. Hypoactive bowel sounds in two quadrants D. Abdominal distention

Correct Answer is A

Explanation

A: The passage of flatus is a clear indication that intestinal function is returning. It shows that the gastrointestinal tract is beginning to move gas through the intestines, which is a positive sign of recovery after abdominal surgery.

B: A request for a cup of tea and some toast indicates that the client is feeling better and has an appetite, but it does not specifically indicate the return of intestinal function.

C: Hypoactive bowel sounds in two quadrants suggest reduced intestinal activity, which is not a sign of returning intestinal function. Normal bowel sounds should be present in all quadrants.

D: Abdominal distention can indicate a buildup of gas or fluid in the intestines, which is not a sign of returning intestinal function. It may suggest an obstruction or other complications.

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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

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