A nurse is documenting subjective data collected from a client during an interview. Which statement is the most appropriate for documentation?
Client's vital signs indicate dizziness and nausea
Client denies any symptoms of dizziness or nausea
Client appears to be uncomfortable and dizzy.
Client reports, feel dizzy and nauseous
The Correct Answer is D
A. Client's vital signs indicate dizziness and nausea: Vital signs provide objective data, not subjective experiences. Dizziness and nausea are reported by the client and cannot be inferred solely from vital signs.
B. Client denies any symptoms of dizziness or nausea: This statement is appropriate only if the client explicitly states they do not have these symptoms. It does not reflect the presence of reported symptoms.
C. Client appears to be uncomfortable and dizzy: Observing discomfort is objective, but “appears dizzy” is subjective and should be documented as reported by the client rather than inferred by the nurse.
D. Client reports, feel dizzy and nauseous: Documenting the client’s own words accurately reflects subjective data. Using quotation marks or the phrase “reports” ensures clarity that these are the client’s statements, which is the standard for documenting subjective findings.
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Related Questions
Correct Answer is C
Explanation
A. Acupuncture is a conventional therapy that replaces your current treatment: Acupuncture is not considered conventional Western medicine. It is typically used alongside standard treatments rather than replacing them entirely.
B. Acupuncture is a traditional therapy that replaces the need for medication: While acupuncture has traditional origins, it does not inherently replace prescribed medications. Recommending it as a replacement could compromise pain management and patient safety.
C. Acupuncture is a complementary therapy that can enhance the effectiveness of your current treatment: Complementary therapies are used alongside conventional treatments to improve outcomes, reduce symptoms, or support well-being. Acupuncture can help manage chronic pain while the patient continues standard medical therapy.
D. Acupuncture is an alternative therapy that works independently of other treatments: Alternative therapy implies it replaces conventional care. In this scenario, acupuncture is intended as an adjunct rather than a substitute.
Correct Answer is A
Explanation
A. Pupils constrict when looking at a close object: The oculomotor nerve (cranial nerve III) controls pupillary constriction via the parasympathetic fibers and accommodates the lens for near vision. Pupillary constriction with accommodation indicates intact oculomotor function.
B. Absence of red reflex: Absence of a red reflex indicates media opacity (e.g., cataract) or retinal abnormality, not necessarily oculomotor nerve function. This finding is unrelated to cranial nerve III integrity.
C. Pupils remain fixed and non-reactive: Fixed, non-reactive pupils suggest oculomotor nerve damage or severe intracranial pathology affecting parasympathetic fibers. This indicates impaired cranial nerve III function.
D. Pupils dilate in response to light: Normally, pupils constrict in response to light. Dilation instead of constriction indicates oculomotor nerve compromise or sympathetic overactivity, reflecting impaired parasympathetic control.
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