The client is being interviewed by the nurse and is asked what symptoms they have had to bring them to the clinic. Which of the following data collected is considered subjective?
A) Blood pressure of 110/60 mm Hg
B) Client states, "My chest feels tight."
C) Bowel sounds present in 4 quadrants
D) Client's skin is warm and dry.
B
Feedback:
Subjective data are statements the client makes about what he or she feels. The other data are objective because they are facts that are obtained through observation.
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The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees
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Which of the following phases of the nursing process encompasses the establishment of a baseline to formulate the care plan?
A) Assessment B) Nursing diagnosis C) Planning D) Implementation
A client who is to be discharged the next day tells the nurse that once he's released he will make sure his wife will never again be able to have him committed to a psychiatric hospital. What action should the nurse take?
A. None, because no explicit threat has been made B. Immediately cancel the client's discharge C. Call the client's wife and report the threat D. Report the incident to the client's therapist and document
As you assess C.W.'s stoma and drainage, what would indicate that they are healthy? Select all
that apply. a. The stoma will be in the shape of a donut. b. The stoma will be level with the skin. c. The stoma will be a uniform medium cherry red in color. d. The stoma will be light pink, and an occasional dark spot might appear. e. The skin around the stoma should be intact. f. The drainage will be thick and dark brown in color.