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 C
Explanation
The client received a dose of clopidogrel at 2200. Clopidogrel is an antiplatelet drug that increases the risk of bleeding during and after a liver biopsy. The healthcare provider should be informed of this medication and decide whether to postpone the biopsy or administer reversal agents.
Choice A is wrong because being NPO since 2300 is a standard preparation for a liver biopsy.
Choice B is wrong because pain in the left lower quadrant and constipation are not related to the liver biopsy and do not pose an immediate risk.
Choice D is wrong because having an allergy is not relevant to the liver biopsy unless it is an allergy to the local anesthetic or contrast agent used.
Correct Answer is B
Explanation
Interview the client privately and ask if anyone is harming her.
This is because the nurse has a duty to assess the client for possible elder abuse and report any suspicions to the appropriate authorities.
The nurse should not assume that the son is the abuser or that the client will disclose the abuse without being asked directly.
The nurse should also respect the client’s autonomy and privacy and not confront the son or provide an elder abuse brochure without the client’s consent.
Choice A is wrong because it may imply that the client is responsible for preventing the abuse or that the nurse has already made a judgment about the situation.
It may also be ineffective if the client is unable or unwilling to read the brochure or seek help. Choice C is wrong because it may delay the assessment and intervention for the client.
It may also be biased and unfair to observe the son without interviewing him or the client first.
Choice D is wrong because it may violate the client’s rights and preferences.
It may also be premature to report the abuse without confirming it with the client or obtaining more evidence.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.