Author Question: Family of a client demonstrating confusion state that this is not the client's usual behavior. How ... (Read 183 times)

corkyiscool3328 · **on:** Jul 23, 2018

Family of a client demonstrating confusion state that this is not the client's usual behavior. How should the nurse document this data?

1. Inference
2. Subjective data
3. Objective data
4. Secondary subjective data

Question 2

The nurse provides a back rub to a client after administering a pain medication with the hope that these two actions will help decrease the client's pain. Which phase of the nursing process is this nurse implementing?

1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation

DHRUVSHAH · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 3
Rationale 1: Inference is making a judgment, and that is not what is described in the question.
Rationale 2: The information provided by the spouse is not subjective because it is an observation by someone familiar with the client's usual behavior.
Rationale 3: Information supplied by family members, significant others, or other health professionals are considered subjective if it is not based on fact. Because this information is factual, in that the spouse is able to provide the nurse with information about the client's routine behavior and patterns, this is objective data.
Rationale 4: The information provided by the spouse is not subjective because it is an observation by someone familiar with the client's usual behavior.

Answer to Question 2

Correct Answer: 3
Rationale 1: Assessment is gathering data, and this is not what is described in the question.
Rationale 2: Diagnosis is identifying patterns and making inferences, and this is not what is described in the question.
Rationale 3: Implementation is that part of the nursing process in which the nurse applies knowledge to perform interventions.
Rationale 4: Evaluation is making criterion-based evaluations, and this is not what is described in the question.