Assessment Data: The patient's incision is clean, dry, and intact with staples.
A nurse is collecting data during the assessment of a patient.
During the assessment, the nurse collects both subjective and objective data.
Determine which data is subjective.
The patient refused breakfast after vomiting 200 mL green emesis.
The patient reports having sharp, burning pain with urination.
The patient's catheter drained 400 mL of urine during the last 8 hours.
The patient complains of extreme nausea upon awakening.
The patient refused breakfast after vomiting 200 mL green emesis.
The patient reports having sharp, burning pain with urination.
The patient's catheter drained 400 mL of urine during the last 8 hours.
The patient complains of extreme nausea upon awakening.
Correct Answer : B,D
Choice A rationale
"The patient refused breakfast after vomiting 200 mL green emesis" is objective data. Vomiting and the amount and color of emesis are observable and measurable facts that can be directly assessed by the nurse.
Choice B rationale
"The patient reports having sharp, burning pain with urination" is subjective data. Pain is a symptom experienced and described by the patient; it cannot be objectively measured or directly observed by the nurse. The description of the pain (sharp, burning) is the patient's personal perception.
Choice C rationale
"The patient's catheter drained 400 mL of urine during the last 8 hours" is objective data. The amount of urine output via a catheter is a measurable quantity that the nurse can directly observe and record.
Choice D rationale
"The patient complains of extreme nausea upon awakening" is subjective data. Nausea is a feeling reported by the patient and is a subjective experience. The intensity ("extreme") is also based on the patient's personal perception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Incorrect organization of health assessment findings relates to how the nurse collects and structures patient data, which may impact the accuracy of diagnosis and care planning but is less likely to be the primary cause of frustration with a patient's cultural health practices.
Choice B rationale
While a patient's insistence on alternative remedies and spiritual practices might indicate coping mechanisms, it doesn't directly explain the nurse's frustration. The frustration likely stems from a conflict in beliefs or approaches to healthcare rather than the patient's ability to cope.
Choice C rationale
Cultural differences encompass the values, beliefs, and practices that influence a person's perception of health, illness, and healthcare. A patient's preference for herbal remedies, prayer, and a spiritual healer over conventional medical treatment reflects cultural health-related practices that may differ significantly from the nurse's professional training and beliefs, potentially leading to frustration.
Choice D rationale
Delay in psychosocial development refers to a lag in achieving expected developmental milestones related to social and emotional functioning. While it can influence a patient's health behaviors, it is less directly related to the nurse's frustration with culturally based healthcare choices. .
Correct Answer is C
Explanation
Choice A rationale
The orientation phase of the interview typically involves introducing oneself, explaining the purpose of the interview, and establishing rapport with the patient. Asking about the drug list occurs after this initial introduction.
Choice B rationale
The termination phase is the concluding part of the interview, where the nurse summarizes key information and discusses the plan of care. Medication history is gathered much earlier in the assessment.
Choice C rationale
The working phase is where the nurse actively collects data about the patient's health history, current condition, medications, and other relevant information. Asking about the drug list, including herbal supplements and over-the-counter medications, is a key component of this data gathering process.
Choice D rationale
The pre-interaction phase occurs before meeting the patient and involves the nurse reviewing available information such as the patient's chart. The actual questioning of the patient happens later.
Choice E rationale
The evaluation phase occurs after interventions have been implemented to assess their effectiveness. It is not the phase where the initial assessment and data collection, including medication history, take place. .
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