A nurse is conducting a patient’s history and physical examination. Which information should the nurse consider as subjective data?

Petechiae

Nausea

Cyanosis

Fever

Answer and Explanation

The Correct Answer is B

Choice A rationale

Petechiae, or small red or purple spots on the skin caused by minor bleeding from broken capillary blood vessels, are an objective finding. They can be seen and evaluated by the nurse during a physical examination.

Choice B rationale

Nausea is a subjective symptom. It is something the patient experiences and reports, but it cannot be directly observed or measured by the nurse.

Choice C rationale

Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective finding. It can be observed by the nurse during a physical examination.

Choice D rationale

Fever is an objective finding. It can be measured by the nurse using a thermometer.

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Correct Answer is C

Explanation

Choice A rationale

Establishing a patient relationship is important, but it’s not the first action the nurse should take. The nurse must first ensure safety for all involved.

Choice B rationale

Exploring the truth of the patient’s statements is a part of the therapeutic process, but it’s not the first step. The immediate concern should be to ensure safety.

Choice C rationale

Setting behavioral limits for the patient is the first action the nurse should take. This is crucial in managing a patient who has shown aggressive behavior. It helps to establish boundaries and expectations, which can prevent further aggressive incidents.

Choice D rationale

While it’s important to explain to the patient that the behavior was unacceptable, this is not the first action. The immediate priority is to ensure safety by setting behavioral limits.

A. “This is the medication that your doctor wants you to take.”. B. “Sometimes the same pill comes in a different color.”. C. “I will check your medication order again.”. D. “Let me explain the purpose of the medication.”. .

Correct Answer is C

Explanation

Choice A rationale

Telling the patient that this is the medication their doctor wants them to take does not address the patient’s concern about the color of the pill.

Choice B rationale

While it’s true that the same medication can sometimes come in different colors, this response does not confirm that the orange pill is the correct medication for the patient.

Choice C rationale

Checking the medication order again is the best response. This will ensure that the patient is receiving the correct medication.

Choice D rationale

Explaining the purpose of the medication does not address the patient’s concern about the color of the pill.

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A nurse is conducting a patient’s history and physical examination. Which information should the nurse consider as subjective data?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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