A nurse is assessing a client who reports leg pain after walking for 10 minutes. Which of the following findings should the nurse document as objective data?
The client walks with a limp.
The client rates their pain as 3 on a scale of 0 to 10.
The client describes the pain as burning.
The client's partner states the client had burning leg pain.
The Correct Answer is A
Rationale:
A. The client walks with a limp is correct because objective data consist of observable and measurable signs that the nurse can verify independently. In this case, the limp is a physical behavior that can be seen and assessed directly, providing evidence of a possible musculoskeletal or vascular problem. Objective findings are critical for forming a baseline assessment, guiding further evaluation, and supporting clinical decision-making.
B. The client rates their pain as 3 on a scale of 0 to 10 is incorrect because pain intensity is subjective data. It reflects the client’s personal perception of discomfort, which cannot be independently measured or verified by the nurse. Although important for understanding the client’s experience and guiding pain management, it does not qualify as objective data.
C. The client describes the pain as burning is incorrect because the description of pain quality is also subjective. The term “burning” conveys the client’s personal sensation and cannot be directly observed or quantified by the nurse. Subjective data are essential for holistic assessment but differ from measurable, observable signs.
D. The client's partner states the client had burning leg pain is incorrect because this is second-hand subjective information. While it can be documented as reported by another person, it is not considered objective data since it is not a direct observation or measurement performed by the nurse. Objective data must be verifiable and independent of another person’s interpretation.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Terminate the nurse's employment immediately is incorrect because while disciplinary action may be warranted, the priority is ensuring the nurse receives help and preventing harm to patients. Immediate termination without support does not address the underlying substance use disorder and could worsen the situation.
B. Reassign the nurse to a less stressful department is incorrect because simply changing the work environment does not address the addiction or underlying stressors. Without appropriate intervention, the nurse may continue to self-medicate and pose safety risks.
C. Provide the nurse with resources for substance abuse counseling and support is correct because the primary intervention focuses on rehabilitation, safety, and professional accountability. Early intervention through counseling, employee assistance programs, or referral to a professional monitoring program helps the nurse recover, ensures patient safety, and addresses the root cause of the behavior.
D. Ignore the situation to avoid causing workplace tension is incorrect because inaction endangers patients, violates professional standards, and fails to support the nurse’s health. Substance misuse in healthcare is a serious safety and ethical concern that must be addressed promptly.
Correct Answer is A
Explanation
Rationale:
A. Engaging the client in a conversation about their thoughts and feelings regarding their pain experience is correct because Jean Watson's theory of transpersonal caring emphasizes the holistic connection between nurse and patient, focusing on the emotional, spiritual, and psychosocial dimensions of care. By exploring the client’s subjective experience of pain, the nurse fosters a caring relationship that promotes healing beyond physical symptom management.
B. Administering pain medication as prescribed is incorrect because while this addresses physical comfort and is essential for symptom relief, it primarily focuses on the biological aspect of care rather than the holistic, relational approach central to transpersonal caring.
C. Providing educational materials on chronic pain management is incorrect because education alone is informative but does not engage the patient in a meaningful, empathetic connection that supports transpersonal healing.
D. Referring the client to a pain management specialist is incorrect because referrals are instrumental in care coordination but do not directly involve the nurse in the therapeutic, interpersonal caring relationship that Watson describes.
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