During an assessment, a client who is not very talkative appears ...

[folubunmi]

During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says leave me alone. Which subjective data should the nurse document?
 
  1. Restlessness
  2. Leave me alone
  3. Not talkative
  4. Pale and diaphoretic

Question 2

While conducting a dressing change, the nurse notes a new area of skin breakdown that was caused from the tape used to secure the dressing. In which phase of the nursing process is the nurse working?
 
  1. Assessment
  2. Diagnosis
  3. Implementation
  4. Evaluation

[joshraies]

Answer to Question 1

Correct Answer: 2
Rationale 1: Restlessness is observable so it is not 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 subjective data.
Rationale 4: Paleness with diaphoresis is observable so this is not 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 scenario.