The nurse observes the client as he paces the floor and talks to himself. The nurse documents this as "Client confused and agitated." This is an example of
An observation
A judgment
Subjective data
Objective data
The Correct Answer is B
Choice A rationale: An observation is a factual statement of what the nurse sees, hears, feels, or smells.
Choice B rationale: This is because the nurse is interpreting the client's behavior and not describing it objectively.
Choice C rationale: subjective data is information that the client tells the nurse, such as feelings, perceptions, or opinions.
Choice D rationale: Objective data is information that the nurse obtains through physical examination, tests, or measurements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Axis 1 is used to document clinical disorders that are the primary focus of management such as schizophrenia, major depressive disorder, and bipolar disorder among others.
Choice B rationale: Axis 3 is used in the documentation of conditions, for instance, asthma, hypertension, and diabetes mellitus among others which are known to have effects on an individual’s mental health.
Choice C rationale: Axis 4 is used in the documentation of environmental and psychosocial issues contributing to a patient’s stress such as financial and family stressors.
Choice D rationale: this is accurate since Axis 2 is used in the documentation of conditions affecting a client’s functioning such as personality disorders and mental retardation.
Correct Answer is A
Explanation
Choice A rationale: TCAs do not have an immediate mechanism of action and may take approximately 2-4 weeks to have an effect on the neurotransmitters involved in mood regulation hence the brain may take some time to adjust to these changes.
Choice B rationale: 1-2 weeks is too short, and may lead clients to feel discouraged or frustrated if they do not see any results by then hence informing them of the duration it will take before they can realize a change in their mood or anxiety is crucial.
Choice C rationale: 3-4 days is too short, and may lead clients to feel discouraged or frustrated if they do not see any results.
Choice D rationale: 1-2 days is too short and unrealistic gives the client false expectations and may make them think that the drugs are ineffective in their mood and anxiety control.
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