An experienced nurse has just walked into the room of a client to whom

An experienced nurse has just walked into the room of a client to whom the nurse has been assigned for the shift. Which of the following might be a significant observation that could influence the inclusion of a new nursing diagnosis?

1. The client’s eyes are closed.
2. The client’s skin is pale and mottled.
3. The client’s spouse is asleep in the chair next to the bed.
4. The television is on and the volume is turned up.

ANSWER

Correct Answer: 2
Rationale: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. A sleeping client would not necessarily be recognized as a significant or relevant observation.