A nurse is gathering data during a health assessment. Which of the following is an example of subjective data?
The patient's blood pressure is 140/85 mmHg.
The patient's respiratory rate is 18 breaths per minute.
The patient reports feeling nausea.
The Correct Answer is C
Rationale:
A. Blood pressure is objective data because it is measurable, observable, and quantifiable. The nurse can obtain this information using a blood pressure cuff and verify it independently. Objective data are considered factual and can be used to track changes over time or compare against established norms. While critical for patient care, it does not reflect the patient’s personal experience or perception.
B. Respiratory rate is also objective data because it can be counted and observed. It provides a concrete measure of physiological function and is not influenced by the patient’s subjective feelings. Objective data like vital signs are crucial for detecting trends, assessing baseline health, and identifying early signs of deterioration.
C. The patient reporting feeling nausea is subjective data, meaning it is based on the patient’s personal experience and cannot be directly measured by the nurse. Subjective data include symptoms such as pain, fatigue, dizziness, anxiety, or nausea. This type of information is essential for understanding the patient’s perception of illness, guiding interventions, and planning individualized care. Without eliciting subjective data through careful interviewing, a nurse might miss symptoms that are not apparent through objective measurements alone.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. The dorsalis pedis pulse is palpated on the dorsum (top) of the foot, just lateral to the extensor hallucis longus tendon, between the first and second toes. This pulse represents the continuation of the anterior tibial artery and provides important information about peripheral circulation to the foot and lower extremity. It is frequently assessed in patients with conditions such as peripheral arterial disease, diabetes, or vascular compromise. Assessing the dorsalis pedis pulse helps determine the adequacy of blood flow, detect arterial obstruction, and monitor changes in perfusion over time. A strong, palpable pulse indicates good arterial perfusion, whereas a weak or absent pulse may signal ischemia or arterial blockage, requiring further evaluation.
B. This is the location of the posterior tibial pulse, not the dorsalis pedis. The posterior tibial pulse is palpated behind the medial malleolus (inner ankle) and is also used to assess circulation to the foot, particularly the plantar surface. While both pulses are important in assessing peripheral circulation, they are anatomically distinct.
C. This describes the radial pulse, which is located on the lateral aspect of the wrist near the thumb. The radial pulse is commonly used to assess heart rate, rhythm, and peripheral perfusion to the hand but is not related to the dorsalis pedis pulse or lower extremity circulation.
D. This corresponds to the carotid pulse, which is used to assess central circulation. It is particularly important in emergency situations such as cardiac arrest or shock but does not provide information about peripheral arterial flow in the lower extremities.
Correct Answer is C
Explanation
Rationale:
A. Blood pressure of 130/85 mmHg is slightly above normal, and a respiratory rate of 22 breaths/min is at the upper limit of normal, which may indicate mild tachypnea. Temperature of 100°F is slightly elevated. These values are not considered fully normal for a healthy adult at rest.
B. Heart rate of 55 bpm is slightly below normal, and respiratory rate of 10 breaths/min is at the lower limit, which may be bradycardic or hypoventilating depending on the context. Temperature of 97°F is slightly below average. While some healthy adults may have these values, they are borderline and not considered standard normal ranges.
C. Blood pressure 120/80 mmHg, heart rate 72 bpm, respiratory rate 16 breaths/min, and temperature 98.6°F all fall within the accepted normal range for a healthy adult at rest. This set accurately represents normal adult vital signs.
D. Blood pressure 140/90 mmHg is considered elevated (stage 2 hypertension), and heart rate 100 bpm is at the upper limit of normal. Temperature 99.5°F is slightly elevated. Overall, these values indicate borderline or mildly abnormal vital signs rather than fully normal values.
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