A nurse is documenting subjective data collected from a client during an interview. Which statement is the most appropriate for documentation?

Client's vital signs indicate dizziness and nausea

Client denies any symptoms of dizziness or nausea

Client appears to be uncomfortable and dizzy.

Client reports, feel dizzy and nauseous

Answer and Explanation

The Correct Answer is D

A. Client's vital signs indicate dizziness and nausea: Vital signs provide objective data, not subjective experiences. Dizziness and nausea are reported by the client and cannot be inferred solely from vital signs.

B. Client denies any symptoms of dizziness or nausea: This statement is appropriate only if the client explicitly states they do not have these symptoms. It does not reflect the presence of reported symptoms.

C. Client appears to be uncomfortable and dizzy: Observing discomfort is objective, but “appears dizzy” is subjective and should be documented as reported by the client rather than inferred by the nurse.

D. Client reports, feel dizzy and nauseous: Documenting the client’s own words accurately reflects subjective data. Using quotation marks or the phrase “reports” ensures clarity that these are the client’s statements, which is the standard for documenting subjective findings.

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Correct Answer is D

Explanation

A. Place the client in a prone position to improve oxygenation: Prone positioning may improve oxygenation in certain critically ill patients, but it is not the first step for a client with an SpO₂ of 90%. Immediate assessment is necessary before changing position.

B. Notify the provider and prepare for intubation: While persistent hypoxemia may eventually require provider notification, intubation is not indicated without assessment of the patient’s overall respiratory status. Premature escalation can lead to unnecessary interventions.

C. Increase oxygen via nasal cannula to 2 L/min: Administering supplemental oxygen may be appropriate, but initiating treatment without assessing for accuracy of the reading and current signs of respiratory distress could mask underlying issues or result in improper dosing.

D. Verify the reading and assess for signs of respiratory distress: The priority action is to confirm the SpO₂ measurement and evaluate for signs of hypoxia, such as increased work of breathing, cyanosis, or altered mental status. Assessment guides safe, evidence-based interventions and ensures accurate clinical decision-making.

A. Focus solely on providing physical symptom management for the client. B. Advise the client to avoid thinking about the loss to prevent emotional distress. C. Encourage the client to discuss their feelings openly with loved ones. D. Recommend the client to isolate themselves to cope privately with their grief

Correct Answer is C

Explanation

A. Focus solely on providing physical symptom management for the client: Addressing physical symptoms is important, but anticipatory grief involves emotional and psychological processes. Limiting care to physical management neglects the client’s emotional needs.

B. Advise the client to avoid thinking about the loss to prevent emotional distress: Encouraging avoidance can suppress emotions, increase anxiety, and impede healthy grieving. Anticipatory grief is best addressed through acknowledgment and expression of feelings.

C. Encourage the client to discuss their feelings openly with loved ones: Facilitating open communication helps the client process emotions, strengthens social support, and promotes coping during the terminal illness. Sharing feelings aligns with therapeutic interventions for anticipatory grief.

D. Recommend the client to isolate themselves to cope privately with their grief: Isolation can exacerbate feelings of loneliness and depression. Supportive interaction with family, friends, or counselors is generally more beneficial for emotional well-being during anticipatory grief.

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A nurse is documenting subjective data collected from a client during an interview. Which statement is the most appropriate for documentation?

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Naxlex Comprehensive Predictor Exams

A client's oxygen saturation is measured at 90% on room air. What action should the nurse take first?

Correct Answer is D

Explanation

Which intervention is most appropriate for a nurse to implement when a client is experiencing anticipatory grief due to a terminal illness diagnosis?

Correct Answer is C

Explanation

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