A nurse is obtaining a breast health history. Which findings represent subjective data? (Select all that apply.)
Client reports nipple discharge for the past week
Axillary lymph node enlargement observed
Skin dimpling noted near the nipple
Client reports breast tenderness before menstruation
A 2-cm firm mass palpated in the right breast
Correct Answer : A,D
Rationale:
A. Client reports nipple discharge for the past week is subjective because the nurse is relying on the client’s personal report of experiencing discharge. The nurse cannot verify this symptom without direct observation at the time of the assessment, and the timing and description come from the client’s own account.
B. Axillary lymph node enlargement observed is objective data. The nurse can directly observe or palpate the lymph nodes, measure size, and document enlargement. It is a tangible sign that does not rely on the client’s perception.
C. Skin dimpling noted near the nipple is also objective data. The nurse observes the abnormal contour or indentation of the breast skin during examination, which can be verified visually and documented.
D. Client reports breast tenderness before menstruation is subjective because it is based on the client’s personal experience of discomfort or pain, which the nurse cannot measure. Pain and tenderness are classic examples of subjective findings because they rely on the client’s report.
E. A 2-cm firm mass palpated in the right breast is objective data. The nurse can physically feel, measure, and document the mass. This finding is tangible and reproducible on examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Unit of measurement (mm Hg) is standard for recording blood pressure. Since this is included in the documentation, there is no need for clarification. Proper units ensure that readings are universally understood and comparable.
B. The location of the blood pressure cuff is essential information that should always be documented. Blood pressure can vary between the left and right arm due to anatomical or vascular differences. Additionally, readings may differ if the cuff is positioned above or below heart level or if the arm is unsupported. Without specifying the arm used and the placement of the cuff, the reading may be misinterpreted, potentially leading to inappropriate clinical decisions, such as unnecessary interventions or missed hypotension or hypertension. For example, a reading from a raised arm may underestimate blood pressure, while a reading from a lowered arm may overestimate it.
C. The client’s position is documented as “sitting up in a chair,” which is clear and appropriate. Proper positioning is critical because blood pressure can change with posture, but in this case, the information is complete and does not require clarification.
D. The systolic blood pressure (102 mm Hg) is clearly indicated. There is no ambiguity in the measurement, so no clarification is needed.
Correct Answer is ["0.8"]
Explanation
Step 1: Identify desired dose and concentration
Desired dose = 30 mg, Concentration = 40 mg/mL
Step 2: Use the formula
Volume (mL) = Desired dose ÷ Concentration
Step 3: Insert values
= 30 ÷ 40
Step 4: Calculate
= 0.75 mL
Step 5: Round to the nearest tenth
≈ 0.8 mL
Final Answer: 0.8
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