During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed and says "leave me alone." Which subjective data should the nurse document?
Not talkative
Pale and diaphoretic
"Leave me alone"
Restlessness
Encourage or provide oral hygiene after mealtime.
The Correct Answer is C
Subjective data refers to information that is reported by the client and cannot be directly observed or measured by the healthcare provider. In this case, the statement "leave me alone" is an example of subjective data that the nurse should document. This information provides insight into the client's feelings and emotions and can help guide the nurse's care and interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Stress urinary incontinence is the involuntary loss of urine during physical activity such as coughing, sneezing, or exercising. It is often caused by weakness of the pelvic floor muscles and/or the urethral sphincter. An appropriate outcome for a client with this condition would be to improve the strength of these muscles. Performing isometric squeezes, also known as Kegel exercises, can help strengthen the pelvic floor muscles and improve sphincter competence. This can help reduce or prevent episodes of incontinence.
Correct Answer is C
Explanation
The nurse's role in the informed consent process is to witness the client's signature on the consent form. It is the responsibility of the physician performing the procedure to explain the procedure, its risks and benefits, and to obtain the client's consent. The nurse can clarify information and answer questions, but it is not their responsibility to explain the procedure or obtain consent.
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