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 A
Explanation
Choice A rationale
The nursing process is a systematic, cyclical method used by nurses to identify and address patient health needs. It involves assessment, diagnosis, planning, implementation, and evaluation, providing a structured approach to problem-solving and the delivery of individualized care.
Choice B rationale
Standardized protocols offer guidelines for specific conditions but do not encompass the holistic and individualized nature of the entire nursing process. The nursing process allows for adaptation and critical thinking beyond pre-established routines to meet unique patient needs.
Choice C rationale
A legal document defining the scope of practice outlines what nurses are legally allowed to do. While the nursing process guides nursing actions, it is a framework for care delivery rather than a legal definition of professional boundaries.
Choice D rationale
While communication is integral to healthcare, the nursing process is more than just a communication tool. It is a comprehensive framework that guides all aspects of nursing care, from initial assessment to the evaluation of outcomes, involving critical thinking and clinical judgment.
Correct Answer is ["B","D"]
Explanation
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.
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