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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Doppler devices are useful for detecting weak pulses, especially in peripheral arteries, but the brachial artery does not provide a direct assessment of the apical heart rate, which reflects actual cardiac contractions at the apex of the heart.
B. Radial pulse measurement can underestimate or miss irregularities such as arrhythmias because it only reflects the peripheral pulse, which may differ from actual cardiac contractions (pulse deficit). Counting for only 30 seconds can also reduce accuracy, particularly in irregular rhythms.
C. The second intercostal space at the right sternal border is the aortic valve auscultation site, not the apex of the heart. This site is used to assess heart sounds like the aortic valve closure, not to measure apical pulse rate.
D. The apical pulse is most accurately measured at the apex of the heart, which is located at the fifth intercostal space at the left midclavicular line. Auscultation here allows direct assessment of ventricular contractions, making it the gold standard for measuring heart rate and rhythm, especially in patients with irregular rhythms or when accurate measurement is critical.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Rationale:
- Dyspnea: Improved. The client reports less shortness of breath and only mild exertional dyspnea compared to previously worsening dyspnea.
- Capillary Refill: No change. Capillary refill times remain the same in both upper and lower extremities.
- Lung sounds: Improved. Previously there were crackles bilaterally; now lungs are clear.
- Bi-lateral lower extremity pulses: No change. Pulses improved from +1 previously to +2, but if considering “today vs last visit” (two weeks ago), they remain +2, so essentially no change since last visit.
- Edema: Improved. Edema resolved; previously +1 pitting in lower extremities, now absent.
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