A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

Temperature 38 C/100.4F, bowels sounds 15/minute

Nausea and stomach cramps.

Occasional cough, respiratory rate 18 breaths per minute

White blood cell count 14,000/mm3, pain 4/10

Answer and Explanation

The Correct Answer is B

A. Temperature and bowel sounds are measurable, making them objective data rather than subjective.

B. These symptoms cannot be measured or observed by the nurse; they are based on the patient's personal experience, making them subjective data.

C. While the cough is subjective, the respiratory rate is measurable and therefore objective. Since the option includes both types of data, it is not the best answer.

D. White blood cell count is objective. Pain rating is subjective, but since this option includes both types of data, it is not the best choice.

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Correct Answer is B

Explanation

A. Patient will be offered laxatives or stool softeners this shift. This is incorrect because offering a medication is an intervention rather than an outcome. Outcomes should focus on the patient’s response to nursing care.

B. Patient will have one soft, formed bowel movement by the end of shift. This is correct because it is a specific, measurable, achievable, realistic, and time-bound (SMART) goal. The outcome directly addresses the problem of constipation and provides a clear indicator of improvement.

C. Patient will not take any pain medications this shift. This is incorrect because withholding pain medication is not an appropriate strategy for managing constipation. Instead, interventions such as increasing fiber, fluids, activity, or stool softeners should be considered.

D. Patient will walk unassisted to the bathroom by the end of the shift. This is incorrect because, although mobility can help improve bowel function, it does not directly measure the resolution of constipation. The outcome should focus on bowel movement frequency and consistency.

A. Ask the patient to make eye contact to determine her affect. B. Notify the health care provider to recommend a psychological evaluation. C. Continue with the interview and document that the patient is depressed. D. Consider cultural differences during this assessment.

Correct Answer is D

Explanation

A. Forcing eye contact may be culturally insensitive.

B. No psychological evaluation is warranted based solely on this behavior.

C. Assuming depression without further assessment is inappropriate.

D. In some Asian cultures, avoiding eye contact can be a sign of respect rather than an indicator of depression or psychological distress.

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A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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