During data collection, the nurse identifies which of the following as subjective data?
1. Laughing during interview
2. "I feel so dizzy."
3. "My dressing is bloody."
4. Temperature is 100.2°F.
2
Rationale 1: The nurse can observe this data, so it is objective data.
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The nurse notices a stain on a newly dried plaster cast over a client's fracture site. The most appropriate method to assess this finding is to
a. assess for a "hot spot" over the stain. b. bivalve the cast and inspect the site. c. draw around the circumference with a pen and record. d. dry the stained area of the cast with a hair dryer.
A patient complains of pain that is well-localized in his arm and "burning." The nurse identifies this as which type of pain?
a. cutaneous pain c. visceral pain b. referred pain d. neuropathic pain
The client with glomerulonephritis has developed acute renal failure (ARF) as a complication. The nurse would expect to note which of the following abnormal findings documented on the client's medical record?
1. Decreased cardiac output 2. Hypertension 3. Bradycardia 4. Decreased central venous pressure
Samuel, a 19-year-old high school student, has been admitted to the psychiatric unit with a diagnosis of adjustment disorder with disturbance of conduct. He assaulted a teacher when he was told he was receiving detentions for a pattern of tardiness
The nurse, while completing rounds, finds the patient in his room crying, and one of his wrists is bleeding from a self-inflicted cut made by a piece of metal from an unknown source. Prioritize each of the following nursing interventions from 1 to 5, with 1 being the highest priority. ___ A. Check the patient's vital signs. ___ B. Assess the wound site. ___ C. Contact the parents. ___ D. Discuss with Samuel what precipitated this event. ___ E. Cleanse and treat the wound site to prevent infection.