A nurse is documenting the data collected from a comprehensive physical exam of a client. Which of the following data should the nurse identify as objective data?
The client states that he has trouble sleeping at night.
The client has a blood pressure of 150/90 mm Hg.
The client reports feeling anxious about his diagnosis.
The client prefers not to discuss his personal issues.
The Correct Answer is B
Choice A reason:
The client states that he has trouble sleeping at night. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.
Choice B reason:
The client has a blood pressure of 150/90 mm Hg. This is objective data because it is information that the nurse observes when conducting a physical assessment. Objective data is measurable and observable.
Choice C reason:
The client reports feeling anxious about his diagnosis. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.
Choice D reason:
The client prefers not to discuss his personal issues. This is subjective data because it is information that the client shares with the nurse spontaneously or in response to a question. Subjective data is based on the client's perception and feelings.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
Choice A reason:
The nurse reports any changes in the client's vital signs, weight, or fluid status to the primary provider. This action demonstrates the skill of collaborating and communicating with other health care providers because it involves sharing relevant and timely information about the client's condition and needs with the primary provider, who can then make appropriate decisions or adjustments to the plan of care. Reporting changes in vital signs, weight, or fluid status is especially important for a client who has chronic heart failure, as these indicators can reflect worsening or improving cardiac function. Reporting changes also follows the ISBARR format of communication, which is a standardized method of exchanging patient information between health care team members.
Choice B reason:
The nurse administers prescribed medications, such as diuretics, beta blockers, and ACE inhibitors. This action does not demonstrate the skill of collaborating and communicating with other health care providers because it is a routine nursing task that does not involve direct interaction or exchange of information with other health care team members. Administering medications is part of the nurse's scope of practice and responsibility, and does not require collaboration or communication with other providers, unless there are questions, concerns, or issues regarding the medication orders.
Choice C reason:
The nurse educates the client about lifestyle modifications, such as sodium restriction, exercise, and smoking cessation. This action does not demonstrate the skill of collaborating and communicating with other health care providers because it is a nursing intervention that focuses on the client's education and self-management, not on the interaction or exchange of information with other health care team members. Educating the client about lifestyle modifications is part of the nurse's role in promoting health and preventing complications, and does not require collaboration or communication with other providers, unless there are discrepancies or inconsistencies in the education materials or messages.
Choice D reason:.
The nurse assesses the client's cardiac function, such as heart sounds, rhythm, and peripheral pulses. This action does not demonstrate the skill of collaborating and communicating with other health care providers because it is a nursing assessment that does not involve direct interaction or exchange of information with other health care team members. Assessing the client's cardiac function is part of the nurse's role in monitoring and evaluating the client's response to treatment, and does not require collaboration or communication with other providers, unless there are abnormal findings that need to be reported or documented.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason:
The client's level of fatigue and weakness is an important data to collect because fatigue is one of the most common and disabling symptoms of MS, affecting about 80% of people with the condition. Fatigue can interfere with the client's daily activities, quality of life, and ability to cope with other symptoms. Weakness is also a common symptom of MS, caused by damage to the nerve fibers that control muscle movements. Weakness can affect the client's mobility, balance, and coordination.
Choice B reason:
The client's cognitive and emotional status is another important data to collect because MS can affect the brain and spinal cord, leading to cognitive impairment in about 50% of people with MS. Cognitive impairment can affect the client's memory, attention, concentration, problem-solving, and decision-making skills. MS can also cause emotional changes, such as depression, anxiety, mood swings, irritability, and euphoria. Emotional changes can affect the client's coping skills, social relationships, and self-esteem.
Choice C reason:
The client's family history and genetic risk factors is not an important data to collect because MS is not a hereditary disease. Although genetic factors may play a role in increasing the susceptibility to MS, they are not sufficient to cause the disease by themselves. MS is thought to be caused by a combination of genetic and environmental factors that trigger an autoimmune response in the central nervous system. Therefore, knowing the client's family history and genetic risk factors will not help in diagnosing or managing MS.
Choice D reason:
The client's vision and hearing acuity is an important data to collect because MS can affect the optic nerve and cause visual disturbances, such as blurred vision, double vision, loss of color vision, pain in the eye, or temporary blindness. Visual disturbances are often the first symptom of MS and can recur or worsen over time. MS can also affect the auditory nerve and cause hearing problems, such as hearing loss, tinnitus, or vertigo. Hearing problems are less common than visual problems in MS but can still affect the client's communication and quality of life.
Choice E reason:
The client's mobility and coordination skills is an important data to collect because MS can damage the nerve fibers that control muscle movements and cause spasticity, tremors, ataxia, dysmetria, or dysdiadochokinesia. These symptoms can affect the client's mobility and coordination skills and increase the risk of falls, injuries, or disability. Assessing the client's mobility and coordination skills can help in planning interventions to improve function, safety, and independence.
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