A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data?
(Select All that Apply.)
Client reports dull, aching pain in lower right calf.
Client reports nausea following administration of pain medication.
Client's oral temperature is 38.4° C (101.2° F).
Client reports the rash on their back is itchy.
Client has a vesicular rash on their upper back.
Correct Answer : A,B,D
A. This is subjective data. The description of pain as "dull" and "aching" is based on the client's personal experience and cannot be measured directly by the nurse. Pain is a subjective symptom because it varies from person to person and is reported by the patient.
B. This is subjective data. Nausea is a feeling or sensation reported by the client and is based on their personal experience. The nurse relies on the client's report to assess this symptom, as it cannot be directly observed or measured.
C. This is objective data. The temperature reading is a measurable, quantifiable fact that can be directly observed and recorded by the nurse using a thermometer. It provides concrete evidence of the client's condition.
D. This is subjective data. Itchiness is a sensation reported by the client and is based on their personal experience. The nurse cannot measure itchiness directly; they rely on the client’s description to understand the symptom.
E. This is objective data. The presence of a vesicular rash is an observable finding that the nurse can see and document. It is a physical characteristic that can be directly assessed and recorded.
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Related Questions
Correct Answer is B
Explanation
A. The NLC allows nurses to practice in multiple states with one license, eliminating the need for separate licenses.
B. The primary purpose of the NLC is to allow nurses to practice in multiple states without obtaining additional licenses.
C. The NLC simplifies the process by allowing nurses to practice with one license in multiple states.
D. Continuing education requirements are generally determined by the nurse's home state, not by the NLC.
Correct Answer is D
Explanation
A. The "Plan" section of a SOAP note outlines the strategies for managing the patient’s condition, including further tests, treatments, and follow-up care. While vital signs can influence the plan of care, they are not documented in this section. Instead, the plan focuses on the next steps in treatment and interventions based on the assessment.
B. The "Assessment" section is where the nurse provides a professional judgment or diagnosis based on the subjective and objective data collected. Vital signs are not typically included in this section. Instead, the assessment would include the nurse’s interpretation of the data and overall evaluation of the patient's condition.
C. The "Subjective" section includes information that the patient reports about their own experience, symptoms, and concerns. Vital signs are objective measurements taken by the healthcare provider, so they do not belong in the subjective section. This section is focused on the patient's personal observations and feelings.
D. The "Objective" section is where measurable, observable data are documented. This includes vital signs such as blood pressure, heart rate, temperature, and respiratory rate, as these are concrete data points that can be objectively assessed and recorded by the healthcare provider.
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