An experienced nurse has just walked into the room of a newly assigned client. Which observation should the nurse use to include a new nursing diagnosis in this client's plan of care?
1. The client's eyes are closed.
2. The client's skin is pale and mottled.
3. The client's spouse is asleep in the chair next to the bed.
4. The television is on and the volume is turned up.
Correct Answer: 2
Rationale: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. A sleeping client would not necessarily be recognized as a significant or relevant observation.
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