A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?
Edema
Heart Rate
Chills
Pallor
The Correct Answer is C
A. Edema:
Edema refers to the presence of swelling caused by an accumulation of fluid. While the nurse can observe and measure edema, the sensation of swelling itself is subjective and based on the client's perception.
B. Heart Rate:
Heart rate is an objective measure of the number of heartbeats per minute. It can be measured and observed by the healthcare provider, making it an objective data point.
C. Chills
Subjective data refers to information that is based on the client's personal experiences, perceptions, and feelings. Chills, which describe a feeling of coldness often associated with shivering, are a subjective symptom that the client experiences.
D. Pallor:
Pallor refers to an unusually pale or white skin color. While the nurse can observe and assess the color of the skin, the client's perception of pallor is subjective.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Regular deep respirations interspersed with periods of apnea:
This describes periodic breathing, which is different from Cheyne-Stokes respirations. Periodic breathing consists of regular cycles of deep respirations followed by periods of apnea.
B. A pattern of crescendo-decrescendo respirations followed by a period of apnea
Cheyne-Stokes respirations are characterized by a pattern of crescendo-decrescendo respirations, meaning that the depth and rate of breathing gradually increase and then decrease. This is followed by a period of apnea, during which there is a temporary cessation of breathing. The cycle then repeats.
C. Patient breathing less than 10 breaths per minute:
This describes bradypnea, which is an abnormally slow respiratory rate. Cheyne-Stokes respirations involve rhythmic, cyclical changes in respiratory rate and depth.
D. Patient breathing shallow and more than 24 breaths per minute:
This describes tachypnea, which is an abnormally fast respiratory rate. Cheyne-Stokes respirations are characterized by a distinct pattern of alternating crescendo-decrescendo respirations followed by apnea.
Correct Answer is ["B","D","E"]
Explanation
A. Wait 30 min and return to measure the oral temperature:
Waiting 30 minutes may not be necessary. It's more practical to take immediate steps to address potential factors affecting the reading.
B. Provide the client a sip of warm water, wait 5 min, and measure the temperature:
This can be a reasonable and practical approach to stimulate blood flow in the oral cavity and achieve a more accurate oral temperature reading.
C. Document that the nurse was unable to measure the client’s temperature:
Before documenting an inability to measure the temperature, the nurse should attempt appropriate interventions, such as warming the oral cavity or using an alternate route
D. Determine if the client has eaten or drank within the last 15 minutes:
Eating or drinking something cold shortly before taking an oral temperature can result in a lower reading. Checking for recent intake is important to ensure the accuracy of the measurement.
E. Use an alternate route (i.e., axillary, rectal) to take the client’s temperature:
If the oral temperature reading remains difficult to obtain or is not reliable, using an alternate route may be necessary. However, this depends on the client's condition, the reason for the temperature measurement, and the healthcare facility's protocols.
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