The nurse is taking information for the client's database. The ...

[shenderson6]

The nurse is taking information for the client's database. The client is not very talkative; is pale, diaphoretic, and restless in the bed; and tells the nurse to just leave me alone.
 
  Which of the following is an example of subjective data regarding this client?
  1. Restlessness
  2. Leave me alone
  3. Not talkative
  4. Pale and diaphoretic

Question 2

The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing.
 
  This would be an example of which phase of the nursing process?
  1. Assessment
  2. Diagnosis
  3. Implementation
  4. Evaluation

[cuttiesgirl16]

Answer to Question 1

Correct Answer: 2
Rationale 1: Restlessness is observable so it is not an example of subjective data.
Rationale 2: Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the client's sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations.
Rationale 3: Not being talkative is observable so it is not an example of subjective data.
Rationale 4: Paleness with diaphoresis iare observable so it is not an example of subjective data.

Answer to Question 2

Correct Answer: 1
Rationale 1: Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.
Rationale 2: Diagnosis is identifying the client's response to the problem. Implementation is what the nurse does to help the client reach a goal, and then the goal is evaluated.
Rationale 3: Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment.
Rationale 4: The goal of the intervention is evaluated but that is not what is being described in this item..

[shenderson6]

Excellent

[Perkypinki]

TYSM