The nurse is reviewing information about a client and notes the following documentation Client is confused. The nurse recognizes this information is an example of what?

A) Subjective data
B) A data cue
C) An inference
D) Primary data


Ans: C

Making a judgment that the client is confused is an inference. An inference must be validated with subjective and/or objective data cues. Sources of data cues can be primary or secondary.

Nursing

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Which of the following clinical findings among older adults is most unlikely to warrant further investigation and possible treatment?

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The rehabilitation team works towards maximizing the patient's independence. As members of the team, what do nurses do?

A) Encourage families to become paraprofessionals in rehabilitation B) Make the patient the center of the team C) Recognize the importance of informal caregivers D) Make patients and families to work together

Nursing

During the first 24 hours postburn, fluid replacement is the treatment priority. The assessment that would alert the nurse that the fluid protocol is ineffective is:

1. rectal temperature of 101ยบ F. 2. urine output of 20 mL/hour. 3. crackles in the lower left lobe. 4. marked edema in the burn area.

Nursing

The nurse, caring for a patient with increased intracranial pressure, assesses an increase in the intracranial pressure that is equal to the patient's mean arterial pressure

Which of the following do these findings indicate to the nurse? 1. hydrocephalus 2. Cushing's triad 3. hypoxemia 4. hypercapnia

Nursing