Answer to Question 1
ANS: C
Patients' feelings about a situation or comments about how they are feeling are examples of subjective data. Data shared by a source verbally are considered subjective. Subjective data may be difficult to validate because they cannot be independently and objectively measured. Data collected from medical records, laboratory, and diagnostic test results, or physical assessments are objective. Objective data (i.e., signs) consist of observable information that the nurse gathers on the basis of what can be seen, measured, or tested. Subjective data (i.e., symptoms) are spoken. Primary data consist of information obtained directly from a patient. Secondary data are collected from family members, friends, other health care professionals, or written sources such as medical records and test results.
Answer to Question 2
ANS: A
During the assessment step, patient care data are gathered through observation, interviews, and physical assessment. In the diagnosis step, patient data are analyzed, validated, and clustered to identify patient problems. Each problem is then stated in standardized language as a specific nursing diagnosis to provide greater clarity and universal understanding by all care providers. The implementation step includes initiating specific nursing interventions and treatments designed to help the patient achieve established goals or outcomes. In the evaluation step, the nurse determines whether the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
The nurse is using Standard Precautions to draw blood.
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Stand in a doorway and hook your fingertips on both sides about chest level or lower.
A partnership between the patient and the health care provider.