A nurse is documenting data collection findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

Client reports the rash on their back is itchy

Client reports nausea following administration of pain medication.

Client has a raised, red rash on their upper back.

Client reports dull, aching pain in lower right calf.

Client's oral temperature is 38.4° C (101.2° F).

Answer and Explanation

Correct Answer : A,B,D

A.   This entry reflects the client’s personal experience and perception of the rash. It is not measurable and relies on the client’s description.

B.   This statement is also based on the client’s experience and feelings about their condition after taking medication. It is a personal report and not an observable finding.
C.   This is an observation made by the nurse. The description of the rash is measurable and can be documented as a physical finding.
D.   Similar to options A and B, this entry describes the client’s perception of pain. It is a personal
experience that cannot be directly measured.
E.   This is a measurable finding obtained through a thermometer. It provides concrete evidence of the
client’s condition and does not rely on the client’s report.

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Correct Answer is C

Explanation

A. Cultural factors include beliefs, values, and practices that influence a person’s health behaviors and decisions. While cultural considerations can impact healthcare access and adherence, this client's primary concern about medication affordability is not specifically rooted in cultural issues.
B. Environmental factors refer to external conditions that affect health, such as housing, pollution, and access to healthcare facilities. While living in subsidized housing may relate to the environment, the core issue here is not about environmental conditions but rather about financial resources and their impact on health.
C. Socioeconomic factors encompass an individual’s economic status, including income, education, and occupation. The client’s concern about affording medications is a clear indication of socioeconomic status affecting their health.
D. Health literacy involves the ability to obtain, process, and understand basic health information and services. While health literacy can influence how effectively a person manages their health and navigates the healthcare system, the client's concern about medication costs is more about financial capability than their understanding of health information.

A. Planning B. Implementation C. Evaluation D. Data collection

Correct Answer is A

Explanation

A. The planning step involves setting goals and determining appropriate interventions to achieve desired outcomes for the client. During this phase, the nurse collaborates with the healthcare team, including
the RN, to establish measurable and realistic goals tailored to the client’s needs.
B. This step refers to the execution of the planned interventions. It involves carrying out the nursing actions and strategies that were developed during the planning phase. While important, implementation is not the stage where goals are formulated.
C. Evaluation is the step where the nurse assesses the effectiveness of the interventions and whether the goals have been met. This phase involves reviewing the client’s progress and determining if adjustments are needed for the care plan. Formulating goals occurs prior to this step.
D. This step is part of the assessment phase, where the nurse gathers information about the client’s health status, history, and needs. While data collection is essential for informing the planning process, it does not involve the formulation of goals.

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A nurse is documenting data collection findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge instructions to a client who lives in subsidized housing and is concerned about being able to afford their medications. Which of the following factors should the nurse identify is affecting the client's health?

Correct Answer is C

Explanation

A nurse is working with an RN to admit a new client. Which of the following steps of the nursing process is the nurse using when assisting to formulate goals for a positive outcome?

Correct Answer is A

Explanation

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