A nurse is documenting data collection findings on a client.

Which of the following entries should the nurse identify as subjective data.

Choice A rationale

Evaluation is the final step of the nursing process, where the nurse determines the client's progress toward achieving the established goals and outcomes. This involves comparing the client's current status and responses to the criteria set during the planning phase, and then modifying the care plan as necessary, which occurs after goal formulation.

Choice B rationale

Data collection (Assessment) is the initial step of the nursing process, involving the systematic and continuous gathering of subjective and objective information about the client. This foundational step precedes the identification of problems and the formulation of goals, as the data collected is used to inform and drive the goals developed later in the process.

Choice C rationale

Implementation is the action phase where the nurse performs the planned interventions to achieve the established goals. This step occurs after the planning phase where the goals are formulated, as the goals provide the specific direction and purpose for the nursing actions and interventions carried out by the nurse.

Choice D rationale

Planning is the step where the nurse, in collaboration with the client and other healthcare providers, formulates realistic, client-centered goals and expected outcomes. This step uses the data from the assessment to prioritize needs and then sets specific, measurable criteria for a positive outcome, directly aligning with the scenario described.

Choice A rationale

The Medication Administration Record (MAR) is a legal document used to track the scheduling and administration of all medications. While vital for drug-related information, the MAR is not a comprehensive tool for providing a holistic report on the client's overall status, care plan, or recent changes needed for an ongoing shift report.

Choice B rationale

The Kardex is a client care summary that provides concise, quick reference information about the client's diagnosis, orders, treatments, scheduled tests, and care needs. Although increasingly digitized, this system (or its electronic equivalent) is specifically designed to facilitate organized, efficient shift-to-shift reporting by summarizing key data points.

Choice C rationale

A Narrative chart note is a descriptive written account of an event, assessment, or intervention and is a component of the legal medical record. While it contains valuable data, using an entire narrative note for shift report is inefficient, as the Kardex or a standardized handoff system (like SBAR) is preferred for a structured and time-efficient handoff.

Choice D rationale

Personal notes written during a shift assessment are considered memory aids and are not part of the legal client record. Providing a report based solely on non-validated, personal notes is unacceptable because it is unprofessional, lacks standardization, and risks incomplete or inaccurate information transfer, violating professional standards.