The nurse is collecting data during an initial assessment. The data that can be seen, heard, measured, or felt and is objective is called a(n):
a. symptom.
b. observation.
c. sign.
d. assessment.
C
A sign can be seen, heard, measured, or felt.
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The patient is admitted to the cardiac unit. Everyone admitted to the cardiac unit will have an EKG done unless otherwise ordered. This is an example of which type of order?
a. PRN b. Standing c. One-time d. STAT
The nurse is identifying nursing diagnoses for a patient with gestational hypertension. Which diagnosis would be the most appropriate for this patient?
A) Risk for injury related to fetal distress B) Imbalanced nutrition related to decreased sodium levels C) Ineffective tissue perfusion related to poor heart contraction D) Ineffective tissue perfusion related to vasoconstriction of blood vessels
The nurse is planning care for four infants who were born this shift. Which infant will require the most detailed assessment? An infant whose mother:
A. Has a history of obsessive-compulsive disorder (OCD). B. Has chlamydia. C. Has six other children. D. Has a urinary tract infection (UTI).
Which patient will the nurse assess most closely for an ileus?
a. A patient with a fecal impaction b. A patient with chronic cathartic abuse c. A patient with surgery for bowel disease and anesthesia d. A patient with suppression of hydrochloric acid from medication