A nurse is obtaining a skin assessment history from a client. Which of the following findings represents subjective data?
A 2 cm erythematous lesion is noted
Skin is warm and dry to touch
Capillary refill is 2 seconds
Client reports itching on both arms
The Correct Answer is D
Rationale:
A. A 2 cm erythematous lesion is objective data because it can be observed, measured, and verified by the nurse. Objective data are factual and measurable rather than based on the patient’s personal experience.
B. Skin that is warm and dry to touch is also objective data. The nurse can palpate and assess these characteristics directly, making them measurable and independent of the patient’s perception.
C. Capillary refill of 2 seconds is an objective finding, as it is measurable and can be verified through observation. This data provides information about peripheral perfusion rather than the patient’s personal experience.
D. The client reporting itching on both arms is subjective data, because it reflects the patient’s personal perception and experience. Subjective data cannot be directly measured or observed, but it is essential for understanding symptoms, guiding care, and identifying potential skin conditions such as dryness, allergy, or dermatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Otitis externa, also called "swimmer’s ear," affects the external auditory canal. Common findings include ear pain, tenderness when the outer ear is manipulated, discharge, and canal edema. It does not typically cause a bulging tympanic membrane with decreased mobility, so this option is unlikely.
B. Otitis media is an infection or inflammation of the middle ear. Classic signs include bulging, erythematous tympanic membrane, decreased mobility on pneumatic otoscopy, and sometimes fluid or pus behind the membrane. This combination of findings directly matches the nurse’s observation and is consistent with acute otitis media.
C. Tympanic membrane perforation involves a rupture or hole in the eardrum. Assessment would reveal a visible opening or defect, sometimes with drainage, but not bulging or decreased mobility. Perforation usually relieves pressure rather than causing a tense, bulging appearance.
D. Presbycusis is age-related hearing loss that affects high-frequency hearing over time. It does not cause visible changes in the tympanic membrane, such as bulging or erythema, and is not associated with decreased membrane mobility.
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.
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