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What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.

A.

Inquire about personal and family cardiac history

B.

Ask about fatigue and chest pain

C.

Inspect for intercostal retractions and nasal flaring

D.

Palpate the chest for any thrills and heaves

E.

Auscultate the heart with the diaphragm and bell of stethoscope

Question Solution

Correct Answer : A,B

A. Inquiring about personal and family cardiac history provides essential subjective information on potential hereditary risks and the client’s own cardiac health.

 

B. Asking about fatigue and chest pain allows the nurse to assess symptoms that may suggest cardiac issues, making it critical subjective data.

 

C. Inspecting for intercostal retractions and nasal flaring is part of the objective assessment rather than subjective data.

 

D. Palpating the chest for thrills and heaves is also an objective action, assessing physical findings rather than subjective symptoms.

 

E. Auscultating the heart with the diaphragm and bell of the stethoscope is an objective assessment to detect sounds rather than gathering subjective information from the client.


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View Related questions

Correct Answer is D

Explanation

A. Fluid restriction by mouth is not typically necessary with opioid administration unless other health conditions require it.

B. A low salt diet is unrelated to opioid administration unless there are concurrent health issues like hypertension or fluid retention.

C. A chest x-ray is not indicated solely due to opioid use.

D. Stool softener medication is commonly prescribed alongside opioid medications because opioids frequently cause constipation due to reduced gastrointestinal motility.

E. Antidiarrheal medication is not needed, as opioids are more likely to cause constipation rather than diarrhea.

Correct Answer is E

Explanation

A. Providing care based on predetermined criteria may overlook individual client needs and cultural nuances.

B. Prioritizing hospital unit workflow may not align with the individual needs of clients.

C. Care aligned with professional healthcare values may not address the specific cultural values and preferences of diverse clients.

D. This approach may dismiss the client's autonomy and unique cultural context.

E. Honoring the client's differences and perspectives indicates a commitment to culturally responsive care, recognizing and respecting diverse backgrounds.

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