Which data will the nurse categorize as objective for a patient who has just completed an assessment?
The patient’s lung sounds are diminished bilaterally with expiratory wheezes.
The patient worries that the insurance company will not pay the hospital bill.
The patient wonders if supplemental oxygen at home would be beneficial.
The patient felt less short of breath after receiving a nebulizer treatment.
The Correct Answer is A
Choice A reason: This is the correct choice because the patient’s lung sounds are diminished bilaterally with expiratory wheezes is an example of objective data. Objective data is observable and measurable information that can be verified by the nurse or other health care professionals. The nurse can use a stethoscope to listen to the patient’s lung sounds and document the findings.
Choice B reason: This is an incorrect choice because the patient worries that the insurance company will not pay the hospital bill is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s worry, but can only rely on the patient’s verbal report.
Choice C reason: This is an incorrect choice because the patient wonders if supplemental oxygen at home would be beneficial is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s wonder, but can only rely on the patient’s verbal report.
Choice D reason: This is an incorrect choice because the patient felt less short of breath after receiving a nebulizer treatment is an example of subjective data. Subjective data is what the patient tells the nurse about their symptoms, feelings, perceptions, and concerns. The nurse cannot observe or measure the patient’s feeling, but can only rely on the patient’s verbal report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because providing a warm cup of hot chocolate may make it more difficult for the patient to fall asleep. Hot chocolate contains caffeine and sugar, which are stimulants that can interfere with the sleep cycle and cause insomnia. The nurse should avoid giving the patient any beverages or foods that contain caffeine or sugar before bedtime.
Choice B reason: This is an incorrect choice because giving the patient a gentle backrub may make it easier for the patient to fall asleep. A backrub is a relaxation technique that can reduce muscle tension, pain, and anxiety, and promote comfort and sleep. The nurse should offer the patient a backrub or other soothing interventions before bedtime.
Choice C reason: This is an incorrect choice because encouraging the patient to use the bathroom may make it easier for the patient to fall asleep. Using the bathroom before bed can prevent nocturia, which is the need to urinate at night, and allow the patient to have uninterrupted sleep. The nurse should assist the patient to use the bathroom or provide a urinal or bedpan if needed.
Choice D reason: This is an incorrect choice because giving the patient an extra blanket when cold may make it easier for the patient to fall asleep. Maintaining a comfortable temperature is important for sleep quality and quantity. The nurse should adjust the room temperature and provide extra blankets or fans as requested by the patient.
Correct Answer is A
Explanation
Choice A reason: This is correct. Teaching the patient to wear low-heeled, comfortable, supportive footwear at all times is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet. This can prevent foot injuries, ulcers, and infections that can lead to amputation.
Choice B reason: This is incorrect. Encouraging the patient to participate in tai chi exercises to promote balance is a beneficial intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Tai chi can improve muscle strength, coordination, and flexibility, but it does not protect the feet from injury.
Choice C reason: This is incorrect. Evaluating the patient's blood pressure for orthostatic hypotension is an important intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Orthostatic hypotension is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting. It can be caused by autonomic neuropathy, which affects the nerves that control blood pressure and heart rate.
Choice D reason: This is incorrect. Instructing the patient to wear a medical alert bracelet that identifies risk for falls is a helpful intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. A medical alert bracelet can alert emergency personnel of the patient's condition and medications, but it does not prevent falls or foot injuries.
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