A nurse is conducting a patient’s history and physical examination. Which information should the nurse consider as subjective data?
Petechiae
Nausea
Cyanosis
Fever
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Before administering digoxin, it is crucial to measure the patient’s apical pulse. Digoxin affects the heart rate, and a low pulse could indicate that the dose needs to be adjusted.
Choice B rationale
Offering a light snack is not specifically required before administering digoxin.
Choice C rationale
While it’s always important to monitor a patient’s blood pressure, it’s not specifically required before administering digoxin.
Choice D rationale
Weighing the patient is not specifically required before administering digoxin.
Correct Answer is A
Explanation
Choice A rationale
The symptoms described, including the paradoxical movement of the chest wall (moving inward during inspiration and outward during expiration), are indicative of a flail chest, which is a life-threatening condition that occurs when a segment of the rib cage breaks due to trauma and becomes detached from the rest of the chest wall.
Choice B rationale
Hemothorax is a collection of blood in the space between the chest wall and the lung (the pleural cavity). It’s often caused by chest trauma. It does not cause the chest to move inward during inspiration and outward during expiration.
Choice C rationale
Atelectasis is a complete or partial collapse of the entire lung or area (lobe) of the lung. It does not cause the chest to move inward during inspiration and outward during expiration.
Choice D rationale
Pneumothorax is a collapsed lung. It does not cause the chest to move inward during inspiration and outward during expiration.
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