A nurse prepares to use a penlight during a physical assessment. Which assessment is the nurse performing?

Choice A reason: A heart rate of 72 beats per minute is well within the normal adult range of 60 to 100 beats per minute. There is no clinical indication to report this finding to a provider, as it represents a stable and expected cardiovascular status for a resting adult.

Choice B reason: While the temperature, heart rate, and blood pressure are normal, a respiratory rate of 8 breaths per minute is abnormally low (bradypnea). The normal range for an adult is 12 to 20 breaths per minute. Therefore, the nurse cannot document these findings as entirely within the expected range.

Choice C reason: Bradypnea (8 breaths/min) can lead to inadequate gas exchange and hypoxemia, which often manifests as lightheadedness or dizziness. The nurse must assess the client for symptomatic distress to determine the clinical significance of the low respiratory rate and the potential need for immediate medical intervention.

Choice D reason: Waiting 30 minutes to recheck an abnormal vital sign is unsafe. A respiratory rate of 8 is a significant deviation from normal that requires immediate secondary assessment. The nurse must act now to evaluate the client’s level of consciousness and oxygenation rather than delaying follow-up.

Choice A reason: Subjective data consists of information provided by the patient that cannot be independently verified by the healthcare provider. This typically includes the patient's internal feelings, perceptions, or descriptions of symptoms, such as "I feel hot" or "My skin feels itchy," which are not directly measurable by the nurse.

Choice B reason: Reported data is a subset of subjective information where the patient or a family member recounts past events or symptoms. While important for medical history, it lacks the immediate, verifiable nature of physical findings gathered by a clinician through direct observation or diagnostic tools during the clinical encounter.

Choice C reason: Objective data refers to measurable and observable signs obtained through the senses or diagnostic instruments. Assessing skin temperature (warm), moisture (dry), and color (flushed) through inspection and palpation constitutes objective findings because any trained clinician can observe and verify these physical characteristics during an assessment.

Choice D reason: Emotional data pertains to the psychological or affective state of the patient, such as anxiety, depression, or fear. While a flushed face can sometimes be a physiological manifestation of an emotion like embarrassment, the physical description itself remains a clinical sign rather than an emotional interpretation.