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. A risk diagnosis applies when a problem has not yet occurred but is likely. This patient is already experiencing chest pain and hemodynamic instability, requiring an actual diagnosis.

B. The patient has current symptoms of chest pain, sweating, pallor, hypotension, and an irregular pulse, indicating a medical condition (possibly myocardial infarction). This justifies an actual diagnosis.

C. Syndrome diagnoses involve a cluster of related diagnoses, such as frail elderly syndrome. This patient’s case does not meet that definition.

D. Wellness diagnoses focus on improving health, not addressing an active medical crisis.

A. Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed B. Administering pain-relief medication according to what was given last shift C. Offering pain-relief medication based on the health care provider's orders D. Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past

Correct Answer is D

Explanation

A. Pain is subjective, and patients experience it differently. Dismissing their report based on the procedure undermines their experience and may lead to inadequate pain management.

B. Pain levels fluctuate, and treatment should be based on current assessment rather than past administration. This approach lacks critical thinking and fails to address the patient's individual needs.

C. While following provider orders is necessary, blindly administering medication without assessing the patient's current pain level and preferences is not critical thinking.

D. This approach individualizes care and involves the patient in decision-making, which is a key component of critical thinking in nursing.

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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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