The nurse is interviewing a female client who reports no menstrual periods for 2 months and breast soreness. The nurse would document this data as which classification of signs of pregnancy?
1. Objective
2. Probable
3. Presumptive
4. Positive
3
Rationale 1: Objective findings are those things that are measurable as opposed to subjective findings that are condition reports by an individual that cannot directly be validated.
Rationale 2: Probable signs are those that may be documented by an examiner and include positive pregnancy test, abdominal enlargement, Piskacek's sign, Hegar's sign, Goodell's sign, Chadwick's sign, and Braxton Hicks contractions.
Rationale 3: Presumptive signs of pregnancy are symptoms the client reports that may have multiple causes other than pregnancy. These include amenorrhea, breast tenderness, nausea and vomiting, frequent urination, perceived quickening, skin changes, and fatigue.
Rationale 4: Positive signs of pregnancy have no possible explanation other than pregnancy and include hearing the fetal heart tone and visualization of the fetus with ultrasound or radiology.
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A. Eye lids B. Visual acuity C. Extraocular movements D. Peripheral vision
The following symptom(s) in the patient's history should raise the clinician's suspicion of colon cancer:
A. Alternating constipation and diarrhea B. Narrowed caliber of stool C. Hematochezia D. All of the above
A nurse feels strongly that nursing practice should be based on justice. The action by the nurse that best demonstrates this principle is to
a. allow patients to make their own decisions regarding nursing care. b. make sure all patients get their meals ordered at the same time. c. spend the same amount of time with each patient during the shift. d. use a consistent approach in deciding which patients to see first.
The nurse is caring for a client with depression. The nurse recognizes which assessment findings to be symptoms of depression? (Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. Lack of energy 2. Sleep disturbances 3. Feelings of despair 4. Increased energy 5. Euphoria