A nurse is documenting assessment findings for a client. Which of the following is an example of subjective data?
The client drank 240 mL of water at 0800.
The client's gait is steady while using a walker.
The client cries while answering questions.
The client points to a 6 on the visual analog pain scale.
The Correct Answer is D
A. The client drank 240 mL of water at 0800: This is objective data because it is a measurable and observable fact that can be verified by the nurse. Documentation of intake is based on direct observation rather than the client’s perception.
B. The client's gait is steady while using a walker: This is objective data as it is based on the nurse’s direct observation of the client’s physical performance. It can be measured or assessed without relying on the client’s personal experience.
C. The client cries while answering questions: Crying is an observable behavior, making it objective data. While it may indicate distress, the nurse is reporting what was seen rather than the client’s internal experience.
D. The client points to a 6 on the visual analog pain scale: This is subjective data because it reflects the client’s personal perception of pain, which cannot be independently measured or verified. Pain is inherently subjective, relying on the client’s self-report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A cervical cap is recommended for clients who have an abnormal Papanicolaou (Pap) test: A cervical cap is not recommended for clients with abnormal Pap results because it may irritate the cervix or complicate follow-up care. Clients should wait until any cervical abnormalities are resolved before using this method.
B. Hormonal contraceptive methods decrease the client's risk for hypertension: Hormonal contraceptives, particularly those containing estrogen, can actually increase the risk of hypertension and thromboembolic events in some clients, rather than reduce it. Blood pressure monitoring is recommended during use.
C. Fertility awareness-based methods are more effective than hormonal methods: Fertility awareness methods generally have higher failure rates compared to hormonal contraceptives. Hormonal methods provide more reliable pregnancy prevention when used correctly.
D. Barrier methods can be used by clients who are breastfeeding: Barrier methods, such as condoms, diaphragms, and cervical caps, are safe for breastfeeding clients because they do not affect milk production or hormone levels. They provide effective contraception without interfering with lactation.
Correct Answer is C
Explanation
A. Abdomen: The abdomen is typically used for subcutaneous injections, such as insulin or heparin, due to its fatty tissue. It is not ideal for intradermal injections, which require a thin layer of skin to allow for proper absorption and observation of a wheal.
B. Deltoid: The deltoid muscle is commonly used for intramuscular injections, not intradermal ones. Using this site for intradermal injections could result in the medication being deposited too deeply, affecting absorption and test accuracy.
C. Back of the upper arm: The inner surface of the forearm or the back of the upper arm is the preferred site for intradermal injections, such as tuberculosis or allergy testing. This area has thin skin, minimal subcutaneous fat, and allows for easy visualization of the wheal and monitoring for reactions.
D. Upper back: While the upper back has subcutaneous tissue, it is not commonly used for intradermal injections because it is less accessible for observation and assessment of local reactions. Proper site selection is important for safety and effectiveness.
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