Answer to Question 1
ANS: B
Careful observation and attention to detail help the nurse to notice subtle cues and recognize how best to validate and interpret patient data. The nurse must be careful not to make false assumptions or generalizations regarding the patient's responses to the health concern. The nurse is correct to ask the patient about the upcoming surgical procedure instead of assuming that the patient has limited knowledge. Developing a comprehensive teaching plan is not necessary until further clarification is obtained. Focusing on postoperative treatment plans is important but not the priority at this time. It is not appropriate to contact the surgeon unless the patient demonstrates an actual knowledge deficit.
Answer to Question 2
ANS: B
As patient information is collected, consistency between subjective and objective data must be confirmed. Sometimes, the nurse can use laboratory and diagnostic test results to validate the subjective data. For example, objective data can validate patient subjective data when the patient's hemoglobin level is low, indicating anemia, and the patient complains of feeling fatigued and dizzy. The nurse has the responsibility to attempt to determine the reason behind the patient's complaint. Obtaining a set of vital signs, reviewing the patient's history, and exploring the patient's pain are appropriate actions but cannot validate the current problem.
The patient and his family meet with the nurse to discuss progress on the patient care plan.
A health history is essential in collecting subjective data about metabolic acidosis.
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A patient with exophthalmos.