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).
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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Related Questions
Correct Answer is D
Explanation
A. When a client has a fever, they are at increased risk for dehydration due to fluid loss through sweating and increased metabolic rate. The nurse should encourage adequate fluid intake to help keep the client hydrated.
B. This action is contraindicated. A warming blanket would further elevate the client's body temperature, which is counterproductive when managing a fever. The goal is to help the client cool down, not warm them up.
C. Increasing the room temperature is not advisable. A warmer environment could make the client feel more uncomfortable and may exacerbate their fever. Instead, the nurse should consider cooling measures.
D. Removing excess clothing can help the client cool down and make them more comfortable. It allows for better heat dissipation and can aid in lowering body temperature.
Correct Answer is C
Explanation
A. During this time, the person may be infected but does not exhibit any symptoms. Since the client is already experiencing symptoms (sneezing, productive cough, muscle aches, headache, and fever), they are not in the incubation stage.
B. This stage occurs after the acute phase of an infection when the symptoms begin to subside, and the individual starts to recover. The client is still exhibiting significant symptoms, so this stage does not apply.
C. This is the stage of an infection where the individual experiences the most severe symptoms. The
client’s symptoms, including sneezing, cough, muscle aches, headache, and fever, indicate that they are
likely in this stage, as these signs point to a full-blown illness.
D. The prodromal stage is the period following the incubation stage, where the first signs and symptoms appear but are not yet specific or severe. Symptoms can be vague and may include mild aches or fatigue. Since the client is presenting with significant symptoms, they are beyond the prodromal stage.
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