A patient states, "I feel like the whole room is spinning around me, and it makes me feel nauseous sometimes." That term will the nurse use to document the patient's symptom?
Dizziness
Tinnitus
Vertigo
Otalgia
The Correct Answer is C
A) Dizziness: While the term "dizziness" can describe a range of sensations, it is more general and does not specifically capture the experience of the patient feeling that the room is spinning. Dizziness can include feelings of lightheadedness or imbalance, which are not the primary symptoms the patient is describing.
B) Tinnitus: Tinnitus refers to the perception of sound, such as ringing or buzzing, in the absence of an external source. This term does not relate to the patient's symptoms of spinning sensations and nausea, making it irrelevant in this context.
C) Vertigo: This term accurately describes the sensation of spinning or movement, often associated with inner ear disturbances. The patient's description aligns with vertigo, as it reflects the specific experience of feeling as though the environment is moving, which can indeed lead to nausea.
D) Otalgia: Otalgia refers to ear pain and is not applicable to the symptoms the patient describes. Since the patient is focusing on a spinning sensation and associated nausea, this term does not relate to the presenting issue.
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Correct Answer is ["A","B","C"]
Explanation
A) Blood pressure 150/90: This data is objective because it is a measurable value obtained through direct observation using a sphygmomanometer. It provides a quantifiable assessment of the client's cardiovascular status and can be verified by others, making it an important piece of objective data.
B) Bowel sounds present in all 4 quadrants: The assessment of bowel sounds is objective as it involves physical examination techniques that can be observed and documented by the nurse. The presence of bowel sounds indicates gastrointestinal activity, and this finding can be consistently assessed across different healthcare providers.
C) PERRLA: The abbreviation stands for "Pupils Equal, Round, Reactive to Light and Accommodation." This assessment is objective as it involves specific, observable measurements of the client's pupils during an eye examination. It can be consistently evaluated by different healthcare professionals, ensuring reliable documentation.
D) Anxious about surgical procedure: This statement is subjective as it reflects the client's personal feelings and emotional state. While important for understanding the client's experience, it cannot be measured or observed directly by the nurse and relies on the client's self-reporting.
E) Dyspnea on exertion: While dyspnea can be observed, the phrase "on exertion" refers to the client's subjective experience of breathlessness. Although it can be assessed through observation of respiratory patterns, the experience itself is based on the client's interpretation, making it subjective data.
Correct Answer is ["A","C","D"]
Explanation
A) Include the student and family in a meeting to elicit her feelings about scoliosis and wearing a brace: This intervention is essential as it encourages open communication and allows the student to express her concerns and feelings about her condition and the brace. Involving the family ensures that they can provide support and understanding during this transition.
B) Suggest that the pediatrician prescribe an anti-anxiety agent for the student: While managing anxiety may be important, it is not the nurse's role to suggest medication without a thorough assessment and evaluation by a healthcare provider. This intervention may not be appropriate in the context of providing support for scoliosis.
C) Teach the student and family about clothing that will hide the brace: This intervention is practical and can help the student feel more comfortable and confident while wearing the brace. By discussing clothing options, the nurse can help alleviate some of the psychological stress associated with wearing a visible brace.
D) Provide contact information for a local scoliosis support group to the student and family: Connecting the family with a support group can provide valuable resources and emotional support. It allows them to engage with others who understand their experiences, which can be reassuring and help them navigate the challenges of scoliosis.