A nurse is documenting the data collected from a comprehensive physical exam of a client. Which of the following data should the nurse identify as objective data?
The client states that he has trouble sleeping at night.
The client has a blood pressure of 150/90 mm Hg.
The client reports feeling anxious about his diagnosis.
The client prefers not to discuss his personal issues.
The Correct Answer is B
Choice A reason:
The client states that he has trouble sleeping at night. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.
Choice B reason:
The client has a blood pressure of 150/90 mm Hg. This is objective data because it is information that the nurse observes when conducting a physical assessment. Objective data is measurable and observable.
Choice C reason:
The client reports feeling anxious about his diagnosis. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.
Choice D reason:
The client prefers not to discuss his personal issues. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A:
Positioning the patient in high Fowler's position. This is a correct intervention because it allows for optimal chest expansion and lung ventilation, reducing dyspnea and work of breathing.
Choice B:
Encouraging deep breathing and coughing exercises. This is an incorrect intervention because it may increase dyspnea and fatigue in a patient with COPD who already has difficulty breathing. Instead, the nurse should teach pursed-lip breathing and diaphragmatic breathing techniques to improve gas exchange and reduce air trapping.
Choice C:
Administering bronchodilators and corticosteroids as ordered. This is a correct intervention because these medications help to relax the smooth muscles of the airways, reduce inflammation, and improve airflow in a patient with COPD.
Choice D:
Providing supplemental oxygen via nasal cannula as ordered. This is a correct intervention because oxygen therapy helps to correct hypoxemia, reduce pulmonary hypertension, and improve exercise tolerance and quality of life in a patient with COPD. The nurse should monitor the oxygen saturation and adjust the flow rate according to the prescription and the patient's response.
Choice E:
Restricting fluid intake to prevent fluid overload. This is an incorrect intervention because fluid restriction is not indicated for a patient with COPD unless there is evidence of heart failure or renal impairment. Adequate hydration helps to thin the secretions and facilitate expectoration in a patient with COPD. The nurse should encourage oral fluids unless contraindicated and monitor the fluid balance and electrolytes of the patient.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason:
The client's readiness and motivation to change are crucial factors for the success of CBT, as it requires active participation and homework assignments from the client. CBT is based on the premise that changing maladaptive thoughts and behaviors can improve emotional well-being. Therefore, the client needs to be willing and able to engage in this process and apply the learned skills to their daily life.
Choice B reason:
The availability and accessibility of CBT services are also important factors for the success of CBT, as they determine how often and how easily the client can receive the therapy. CBT is typically delivered in a time-limited and structured manner, with sessions ranging from 8 to 20 weeks. The client needs to have regular access to a qualified CBT therapist who can provide consistent and evidence-based treatment.
Choice C reason:
The cost and duration of CBT sessions are not relevant factors for the success of CBT, as they do not directly affect the quality or effectiveness of the therapy. CBT is generally considered to be a cost-effective and efficient intervention for anxiety disorders, as it can produce lasting benefits in a relatively short period of time. The cost and duration of CBT sessions may affect the client's preference or adherence to the therapy, but they are not essential for its outcome.
Choice D reason:
The compatibility and rapport between the client and therapist are vital factors for the success of CBT, as they influence the therapeutic alliance and the client's trust in the therapist. CBT is a collaborative and goal-oriented therapy that requires a strong working relationship between the client and therapist. The client needs to feel comfortable and supported by the therapist, who can provide empathy, feedback, guidance, and encouragement.
Choice E reason:
The evidence base and efficacy of CBT for anxiety disorders are significant factors for the success of CBT, as they demonstrate the validity and reliability of the therapy. CBT is one of the most researched and empirically supported psychological interventions for anxiety disorders, with numerous studies showing its superiority over other treatments or placebo. The client can benefit from knowing that CBT is based on sound scientific principles and proven techniques.
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