which of the following items of subjective client data would be documented in the medical record by the nurse
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Predictor Exam

1. Which of the following items of subjective client data would be documented in the medical record by the nurse?

Correct answer: D

Rationale: The correct answer is 'Client feels nauseated.' Subjective data refers to the client's sensations, feelings, and perception of their health status. It can only be reported by the client as it is based on their personal experiences. The feeling of nausea is a subjective symptom that the client experiences and can provide insight into their health condition. Choices A and B represent objective data, as they describe observable or measurable findings that can be detected by the nurse. Choice C involves information reported by someone other than the client, making it indirect and not purely subjective.

2. What term is used to describe the sexual response changes among middle-aged men?

Correct answer: B

Rationale: The correct answer is 'Climacteric.' Climacteric specifically refers to the period in middle-aged men characterized by sexual response changes, such as delayed arousal. Menopause, choice A, is incorrect as it is specific to women and marks the cessation of menstrual periods. Generativity, choice C, is unrelated as it refers to the concern for guiding the next generation. Maturity, choice D, is too broad and generally refers to reaching the adult stage of development, not specifically addressing sexual response changes in middle-aged men.

3. A patient has suddenly developed shortness of breath and appears to be in significant respiratory distress. After calling the physician and placing the patient on oxygen, which of these actions is the best for the nurse to take when further assessing the patient?

Correct answer: B

Rationale: In a situation where a patient is in significant respiratory distress, bilaterally percussing the thorax to note any differences in percussion tones is a crucial nursing intervention. Percussion provides instant feedback regarding changes in underlying tissue density, which can give important clues about the patient's physical status. This hands-on assessment technique is readily available and can be performed promptly. Counting the patient's respirations, while important, may not provide as much detailed information as percussion. Ordering a chest x-ray and waiting for the results can cause a delay in assessing and addressing the patient's immediate needs. Inspecting the thorax for new masses and bleeding, although relevant, may not offer as much real-time information about the patient's condition compared to percussion.

4. The NFPA diamond has four colors. The blue diamond:

Correct answer: A

Rationale: The National Fire Protection Agency (NFPA) uses a safety diamond to communicate the level of threat posed by a specific chemical. The blue diamond in the NFPA diamond system signifies potential health hazards associated with the use of that chemical. Choice B is incorrect because the blue diamond does not indicate anything about using water to extinguish fires. Choice C is incorrect as the NFPA diamond does not provide information on treating injuries. Choice D is also incorrect as the blue diamond does not suggest incineration upon disposal; it pertains to health hazards.

5. When providing mouth care to a patient in a coma, what should you do to provide good and safe mouth care?

Correct answer: D

Rationale: When providing mouth care to a patient in a coma, it is crucial to use a special foam swab to brush the tongue and teeth. This method helps maintain good oral hygiene for comatose patients. Special foam swabs are designed to effectively clean all areas of the mouth, including the cheeks and tongue, ensuring thorough care. Using water for mouth care in comatose patients can lead to aspiration, so it is important to avoid this practice. Keeping the head of the bed up alone does not prevent aspiration during mouth care for comatose patients, making choice A incorrect. Merely brushing the tongue (choice C) or using a foam swab only on the tongue (choice B) may not provide the comprehensive mouth care necessary for patients in a coma.

Similar Questions

When examining an older adult, which technique should the nurse use?
Which of these is a correctly stated outcome goal written by the nurse?
What term is used to refer to generalized wasting of body tissues and malnutrition?
The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?
A newly admitted patient with major depression has lost 20 pounds over the past month and has suicidal ideation. The patient has taken an antidepressant medication for 1 week without remission of symptoms. Select the priority nursing diagnosis.

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses