The nurse documents in the progress notes: Admitted to ...

[ishan]

The nurse documents in the progress notes:
 
  Admitted to emergency department accompanied by wife. Patient is alert and oriented, blood pressure is 120/80 mm Hg, and pulse is 80 beats/min. The patient is anxious. He becomes nervous and when asked about his smoking history. Which statement from the nurse's note is the best example of an inference?
  a. Blood pressure reading 120/80 mm Hg
  b. Patient is accompanied by wife.
  c. Patient has a history of smoking.
  d. The patient is anxious.

Question 2

A client approaches the nurse in the health clinic and states, I have been dealing with my husband's illnesses for years. Now my children want me to start babysitting for my grandchildren. I don't know whether I can handle all this.
 
   What is the nurse's interpretation of this woman's statements?
  a. Some events are producing more stress for her than other events.
  b. Her coping abilities are extended to her limit and she is unable to cope.
  c. When there are many stressors or when stressors continue for a long period of time, adaptation is more likely to fail.
  d. Coping strategies that she has used in the past are no longer successful for her now.

[Sophiapenny]

Answer to Question 1

D
The inference in this item is that the patient is anxious. The nurse observes that the patient is nervous and shaky. She can document these observations but she cannot infer that these observations mean that the patient has anxiety. Blood pressure and patient accompaniment by wife are objective data. History of smoking is subjective data.

Answer to Question 2

C
When there are many stressors or when stressors continue for a long period of time, adaptation is more likely to fail. In this item, the client is verbalizing both a concern in caring for a family member over a long period of time and the possibility of dealing with a new stressor: babysitting grandchildren. Some events produce more stress than others. However, a person with good coping skills can usually adapt to a single stressful event, even a demanding one. This client has been managing one stressful event. It is the addition of another that is concerning her. In this item, we are unable to determine that coping strategies are no longer successful because we do not have any information on past coping strategies. Additionally, we cannot determine that she is unable to cope because she states, I don't know whether I can handle all this.

[ishan]

TY

[Sophiapenny]

You're welcome