A patient is nauseated and vomited. She has a red rash on the face and neck, which she says is itchy. She complains of a headache and feels very irritable. Which piece of data is objective?
itching
headache
rash
nausea
The Correct Answer is C
A. itching:
This is a subjective symptom. Itching is a feeling experienced by the patient and cannot be directly observed by the nurse. The patient's report of itching is subjective until the nurse observes any visible signs of scratching or a rash.
B. headache:
Similar to itching, a headache is a subjective symptom. It is a feeling experienced by the patient and cannot be directly observed by others. The patient's report of a headache is subjective until the nurse observes signs such as the patient holding their head or wincing in pain.
C. rash:
In the given context, a red rash on the face and neck is objective data. Objective data refers to measurable and observable information about a patient's condition. In this case, the nurse can directly observe the rash, making it objective. Objective data is factual and can be verified by others.
D. nausea:
Nausea is also a subjective symptom. It is a feeling experienced by the patient and cannot be directly observed by others. The patient's report of nausea is subjective until the nurse observes signs such as the patient looking pale, sweating, or exhibiting other physical symptoms associated with nausea.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Don't worry; this pain won't last forever."
This statement dismisses the patient's concerns and does not encourage open communication about pain. It does not address the patient's current pain experience or provide a basis for effective pain management.
B. "You look pretty comfortable. Are you having any pain?"
While this statement attempts to inquire about the patient's pain, it might not encourage the patient to open up about their pain experience. The patient might downplay their pain to appear strong or not to be a bother.
C. "Is this pain the same as the pain you had yesterday?"
This question is specific and might help in assessing the consistency and nature of the pain. However, it assumes the patient had pain yesterday and does not open the conversation effectively for the patient to express their pain experience freely.
D. "Tell me about the pain you've been having."
This statement is open-ended and encourages the patient to express their pain experience in their own words. It creates a comfortable environment for the patient to discuss their pain, allowing the nurse to gather valuable information about the pain's intensity, location, quality, and factors that aggravate or alleviate it. This approach is patient-centered and allows for a comprehensive pain assessment.
Correct Answer is B
Explanation
A. Patient leaving against medical advice:
When a patient decides to leave the hospital against medical advice, it's crucial to communicate this decision effectively. However, this situation does not specifically require a structured communication tool like SBAR. Rather, it necessitates clear communication to ensure the patient understands the risks and implications of leaving against medical advice.
B. Patient transfer to another facility:
During a patient transfer, especially between different healthcare facilities, it's essential to provide a comprehensive hand-off communication. SBAR is commonly used in such situations.
Situation: Describes the current situation and why the patient is being transferred.
Background: Provides relevant medical history and context.
Assessment: Presents the patient's current condition and vital signs.
Recommendation: Specifies what care and interventions the receiving facility should provide.
Using SBAR in this context ensures that all critical information is passed on accurately, minimizing the risk of errors and improving the continuity of care.
C. Visitor fall:
While a fall involving a visitor is an important incident, it doesn't typically require a structured communication tool like SBAR. Instead, it necessitates immediate response, assessment, and appropriate reporting within the hospital’s incident reporting system.
D. Needle stick injury to a nurse:
In the case of a needle stick injury, prompt reporting and proper follow-up are vital. While communication is crucial, it doesn't usually follow the structured format of SBAR. The nurse needs to report the incident to their supervisor or employee health, which would initiate appropriate protocols for testing, treatment, and documentation. Clear communication is necessary, but it doesn’t typically involve the use of the SBAR tool.
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