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Exhibits

Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.

Rhinitis of right nare present.

Pulse 110 bpm.

Temperature 101.8 F (38.7 C).

Reports tenderness during palpation of sinus cavities.

Reports light sensitivity.

Lymphadenopathy >2 cm.

History of allergies to pollen, dust, animal dander.

Right eye periorbital edema present.

Answer and Explanation

Correct Answer : D,E,G

A. Rhinitis of right nare present: This is an observable sign noted by the nurse during assessment, making it objective data.

B. Pulse 110 bpm: Measured using a monitor or palpation, pulse is a quantifiable, objective finding.

C. Temperature 101.8 F (38.7 C): Body temperature is measured with a thermometer, making it objective data.

D. Reports tenderness during palpation of sinus cavities: Tenderness is a sensation reported by the client, reflecting their personal experience, so it is subjective data.

E. Reports light sensitivity: Light sensitivity is reported by the client and cannot be directly measured, making it subjective.

F. Lymphadenopathy >2 cm: Enlarged lymph nodes are assessed and measured by the nurse, making this objective data.

G. History of allergies to pollen, dust, animal dander: The client provides this information, making it subjective data derived from their personal history.

H. Right eye periorbital edema present: Swelling around the eye is observable, measured, and documented by the nurse, so it is objective data.

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Correct Answer is D

Explanation

A. "Timely and accurate documentation provides a comprehensive database of a client's health.": Accurate documentation creates a detailed record that supports clinical decision-making and continuity of care.

B. "Timely and accurate documentation establishes collaborative goals for care.": Proper documentation allows all members of the healthcare team to develop and coordinate client-centered care plans effectively.

C. "Timely and accurate documentation provides information to the healthcare team.": Documentation ensures that the healthcare team has access to current and relevant client information, supporting safe and effective care.

D. "Timely and accurate documentation prevents legal action from being taken.": While accurate documentation may help protect nurses, it does not prevent legal action. Legal issues can still arise even with correct records, so this statement reflects a misunderstanding of the purpose of documentation.

A. A client with a burn on their forearm sustained from boiling water B. A client with a right ankle fracture unable to place any weight on it C. A client with severe abdominal pain who is pale and diaphoretic D. A client with a head laceration being controlled with pressure

Correct Answer is C

Explanation

A. A client with a burn on their forearm sustained from boiling water: While burns require assessment and care, a forearm burn without signs of systemic compromise is not immediately life-threatening and can wait after more urgent cases.

B. A client with a right ankle fracture unable to place any weight on it: An isolated fracture causes pain and limited mobility but is not life-threatening, making it lower priority in triage compared to clients with potential systemic compromise.

C. A client with severe abdominal pain who is pale and diaphoretic: Pallor and diaphoresis indicate possible shock or serious internal pathology. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

D. A client with a head laceration being controlled with pressure: If bleeding is controlled and the client is stable, this is urgent but not immediately life-threatening, so the client can be assessed after those showing signs of shock or systemic compromise.

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Exhibits Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is educating staff nurses about the goals of timely and accurate documentation of health assessments. Which statement by a staff nurse indicates additional education is needed?

Correct Answer is D

Explanation

The nurse is triaging a group of clients in the emergency department. Which client should be assessed first?

Correct Answer is C

Explanation

A visiting nurse is making a routine home visit for a client who has hypertension, diabetes mellitus, and chronic kidney disease to understand how treatment has been going. Which type of assessment should the nurse use in this situation?

The nurse is caring for a client diagnosed with type 1 diabetes two months ago. The client reports being admitted to the hospital several times due to hypoglycemia. When educating the client about their disease process before discharge, which information should the nurse prioritize?

A nurse is assessing a client whose parent has coronary artery disease (CAD). What should the nurse plan to incorporate into the client's care plan?

A home health nurse is caring for an older adult client who is immobile. What question should the nurse ask to collect information about the client's safety?

A nurse is assessing the abdomen of a client by using a tapping technique over the client's skin with short, sharp strokes to assess the density of underlying structures. What assessment technique is the nurse using?

A nurse manager assesses safety on the medical-surgical floor. For each scenario, click to specify whether each scenario is safe or unsafe.

45. Complete the sentence by selecting from the drop-down lists. A nurse is assessing the gastrointestinal system of a client. The nurse should document dropdown as objective data anddropdown as subjective data.

Exhibits

Review the electronic health record. Which finding(s) should the nurse identify as subjective data? Select all that apply.