A nurse is preparing to interview a client to obtain a health history. Which actions should the nurse take to promote effective communication and accurate data collection? (Select all that apply)

Choice A reason: Pain is a subjective experience that cannot be felt or measured directly by the examiner. Even when quantified using a scale from 0 to 10, the information remains subjective because it relies entirely on the client's personal perception and verbal report of their internal physical state.

Choice B reason: Objective data, also known as signs, are detectable by an observer or can be measured using a standard scale or device. A heart rate of 112 beats per minute is a precise, measurable clinical finding that any trained professional can verify through palpation or electronic monitoring.

Choice C reason: Dizziness is a subjective symptom described by the patient. While the nurse might observe associated signs like staggering or pallor, the actual sensation of "feeling dizzy" is internal and cannot be independently validated through the nurse's senses or physical measurement alone during the assessment.

Choice D reason: Anxiety is an emotional state and is classified as subjective data. Although physiological signs of anxiety—such as sweating or tachycardia—are objective, the client's verbalization of their feelings is a subjective report that the nurse records as part of the health history.

Choice A reason: Documenting 88 mm Hg as the diastolic value is incorrect. While the muffling of sounds (Korotkoff Phase 4) is a significant clinical observation, particularly in children or pregnant women, the standard diastolic pressure for an adult is defined by the complete disappearance of sound (Phase 5).

Choice B reason: According to standard clinical guidelines, the systolic pressure is recorded at the first Korotkoff sound (Phase 1), and the diastolic pressure is recorded when the sounds completely disappear (Phase 5). Therefore, 138/82 mm Hg is the correct representation of the patient's arterial blood pressure.

Choice C reason: There is no evidence in the provided data to suggest an auscultatory gap. An auscultatory gap is a period of silence between systolic and diastolic sounds. Since the nurse heard a continuous progression from tapping to muffling to silence, there is no clinical indication to redo the measurement.

Choice D reason: While recording three numbers (Phase 1/Phase 4/Phase 5) is sometimes done in specific clinical populations, the standard two-number format (Systolic/Diastolic) is the universal requirement for general adult documentation. Including the muffling point is usually unnecessary for routine vital sign recording.