Which of these assessment findings should a nurse record as subjective?
Hives.
Itching.
Vomiting.
Abdominal distension.
The Correct Answer is B
This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the
patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.
For example:
Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.
Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.
Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.
Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:
- Hives: No hives or rashes on the skin are normal.
- Vomiting: No vomiting or nausea are normal.
- Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A client with expiratory wheezing after an albuterol treatment.
This indicates that the client has a severe bronchospasm that is not responding to the medication and may lead to respiratory failure.
The client needs immediate intervention to improve airway patency and oxygenation.
Choice A is wrong because a fasting blood sugar of 187 mg/dL is high but not life- threatening. The normal range for fasting blood sugar is less than 99 mg/dL.
The client may have diabetes or prediabetes and needs further evaluation and treatment, but this is not a priority over choice B.
Choice C is wrong because a client who has been called to surgery 2 hours early may need some preparation and education, but this is not an urgent situation.
The client can wait until the nurse has assessed the other clients.
Choice D is wrong because a blood pressure of 178/90 mmHg is elevated but not critical. The normal range for blood pressure is less than 120/80 mmHg.
The client needs a dose of atenolol, which is a beta
Correct Answer is D
Explanation
temperature 101.8° F(38.8° C), BP 100/60 mm Hg, pulse 98/min, RR 28/min. This set of vital signs indicates that the client may have an infection or sepsis, which are potential complications of an open cholecystectomy. The client has a fever, tachycardia, tachypnea, and hypotension, which are signs of systemic inflammatory response syndrome (SIRS).
Choice A is wrong because it shows mild hypothermia, hypotension, and tachycardia, which could be due to dehydration or blood loss, but not necessarily infection.
Choice B is wrong because it shows a slight fever, normal blood pressure, and bradycardia, which could be due to pain or medication, but not infection.
Choice C is wrong because it shows a low-grade fever, normal blood pressure and pulse, and mild tachypnea, which could be due to inflammation or dehydration, but not infection.
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