At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are

Subjective

Objective and measurable

Reported by the patient

Hidden

Answer and Explanation

The Correct Answer is B

A: Subjective information refers to what the patient experiences and reports, not what is sensed by the observer.
B: Objective signs are those that can be observed and measured by someone other than the patient, such as visual inspections, palpations, and auditory cues.
C: Reported by the patient would be subjective data, opposite of what is sensed and recorded by healthcare providers.
D: Hidden signs would imply they are not readily observable, which contradicts the use of senses to identify them.

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Correct Answer is A

Explanation

A: Due to age-related reductions in gastrointestinal muscle efficiency, which slows the digestive process and can lead to increased water absorption from stool.
B: Overstates the issue, not all elderly patients experience difficulties, and it does not account for individual variability or other influencing factors like diet and medication.
C: Misrepresents the frequency and reasons for laxative use among the elderly, not all of whom misuse these medications.
D: While changes in rectal sphincter elasticity can affect some elderly individuals, it is less commonly a direct cause of constipation compared to decreased peristalsis.

A. Select a cuff that covers 50% of the client's upper arm. B. Place the blood pressure cuff 5 cm (2 in) above the client's antecubital space. C. Elevate the client's arm above the level of the heart. D. Align the artery indicator on the blood pressure cuff with the client's brachial artery.

Correct Answer is D

Explanation

A: The cuff should ideally cover about 80% of the circumference of the upper arm, not just 50%.

B: The cuff should be placed level with the client's heart, specifically aligned with the brachial artery for accurate measurement.
C: Elevating the arm above the level of the heart can lead to an inaccurately low reading.
D: Proper alignment with the brachial artery ensures that the sensor correctly detects the arterial pressure, crucial for accurate readings.

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At the staff education meeting, the nurse explains that it is important to use four senses (sight, touch, hearing, and smell) to determine whether a patient is exhibiting signs of illness or injury. These signs of illness or injury are

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the physical assessment, the nurse asks an elderly female patient if she experiences constipation. The nurse knows that

Correct Answer is A

Explanation

A nurse is preparing to obtain an electronic blood pressure measurement on a client. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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