Question

13) While performing a physical assessment on an 18 year old female client it is noted that the client has bruises in different stages of healing on the abdomen. The nurse is aware that this may be a sign of physical abuse and records in the note,"Client noted to have multiple bruises in different stages of healing in all four quadrants of the abdomen." The nurse underdands that this type of documentation is: A) Recording the client's understanding and perception of problems B) Supporting objective data with specific observations obtained during a physical exam C) Creating redundancies D) Gathering subjective data 14) Which of the following is not a part of data analysis? A) Cluster data B) Document conclusions C) Propose possible Nursing Diagnoses D) Validating data 15) After obtaining a client's weight and height the nurse notes that client's body weight is 10% over the ideal body weight. The nurse is aware that 10% over ideal body weight is considered A) Obese B) Overweight C) Underweight D) Malnourished 16) The nurse is caring for a Client who has had a 3 day history of vomiting. Upon physical assessment the nurse notes that the client has a thready +1 pulse, an increased heart, a low blood pressure in comparison to their baseline data the nurse has reviewed in the chart. The nurse infers from this data that the Client may be: A) Dehydrated B) In renal Failure

Answer 1

13, b, Supporting objective data with specific observation obtained during a physical exam
Objective data can be observable data by physical exam tests etc. subjective data will provide the information gathered from the patient through interviews. Redundancy is a state of being useless to consider as unnecessary documentation.
14, a, cluster data
clustering data is not always suitable for the data set. Data validation makes sure the data is complete. patient data analysis useful for proposing possible nursing diagnoses. for document conclusion data analysis always helpful.
15, b, overweight
10-20% over the ideal body weight considered as overweight, more than 20% ideal body weight considered as obese.underweight ideal body weight will be less than 5%.
16, a, Dehydrated
when the patient dehydrated vital signs for the patient will have a high heart rate, low blood pressure, fast breathing rate. in renal failure, the patient will have associated symptoms. when patients overhydrate there will be neurological changes there. if it is stomach virus patient will have abnormal vital signs including mild, diffuse abdominal tenderness and other symptoms.
17, a,body position
b, emotions
c, pain
d, nicotine
Body position can change blood pressure. blood pressure will be low in the standing position compared to sitting and supine position
Persons' angry and anxiety can increase blood pressure. emotional effects and differ the blood pressure.
pain increases the blood pressure through sympathetic activity
Nicotine contains tobacco products that make the blood vessels narrow that time heartbeat will be high, it causes high blood pressure