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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The appropriate response by the nurse in this situation would be to respect the young man's wish not to look at the wound during dressing changes. This response shows empathy and understanding toward the patient's feelings and emotions and allows him to have control over his own care. It is important for healthcare providers to respect their patient's autonomy and decisions regarding their own care.

A. Client will have freer movement in daily activities. B. Client will ambulate without a walker by 6 weeks. C. Client will not fall. D. Client will ambulate frequently in the house.

Correct Answer is B

Explanation

An appropriate outcome statement for a client with a discharge goal of improved mobility should be specific, measurable, achievable, relevant, and time-bound. In this case, the outcome statement "Client will ambulate without a walker by 6 weeks" meets these criteria. It specifies the desired outcome (ambulating without a walker), provides a measurable goal (6 weeks), is achievable and relevant to the client's goal of improved mobility, and includes a time frame for achieving the goal. The other statements are not specific or measurable enough to be considered appropriate outcome statements.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

Correct Answer is C

Explanation

A discharge goal for a client is to have improved mobility. Which outcome statement did the nurse write appropriately?

Correct Answer is B

Explanation

When planning interventions to promote a client's appetite, which of the following would be included in the client's plan?

A nurse is educating women on the need for calcium to prevent bone loss. What level of prevention does this represent?

A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+ and equal in radial, popliteal, and dorsalis pedis. What does the number "+3" represent?

A nurse is caring for an older adult client who is at risk for skin breakdown. The nurse should use which of the following interventions to help maintain the integrity of the client's skin?

The nurse educator provides developmental testing for kindergarten through third-grade students. Which level of prevention is the nurse performing?

A nurse is providing education to a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the education plan?

While in the dining room at the hospital, the nurse notes a visitor has forceful coughs. Which actions would the nurse take to assist this visitor? Select all that apply: