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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Changing a surgical dressing: This is an example of a nursing implementation. Nurses frequently change dressings as part of their patient care responsibilities.
B. Return demonstration by the patient: This is also an example of a nursing implementation. Nurses often educate patients and then assess their understanding through return demonstrations to ensure the patient can perform tasks correctly at home.
C. Changing an ostomy bag: This is another example of a nursing implementation. It involves hands-on care for patients with ostomies, a responsibility often carried out by nurses.
D. Planning patient outcomes: While planning patient outcomes is crucial for nursing care, it falls more under the category of nursing interventions and nursing process rather than direct implementations.
E. Analyzing assessment data: Analyzing assessment data is part of the nursing process and helps in making decisions about nursing care. While it's essential, it's not a direct implementation action.
Correct Answer is A
Explanation
A. An independent nursing action:
This statement is correct. Preparing a patient for a diagnostic test and providing information about what to expect during and after the test is within the scope of nursing practice. Nurses can independently educate patients and prepare them for procedures based on their knowledge and protocols.
B. The doctor's responsibility:
This statement is incorrect. While doctors order tests and procedures, it is the responsibility of the nursing staff to prepare the patient, provide necessary information, and ensure the patient's understanding and comfort before the procedure.
C. A dependent nursing action that requires the doctor's authorization:
This statement is incorrect. Preparing a patient for a diagnostic test and providing education about the procedure do not require direct authorization from the doctor. Nurses can perform these actions as part of their nursing practice.
D. An interdependent nursing action:
This statement is incorrect. Interdependent nursing actions involve collaboration with other healthcare professionals. Educating the patient about a diagnostic test is primarily an independent nursing action, although collaboration with other team members might be necessary in certain cases.
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