The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Assistive personnel reports the patient walks with a limp

Patient reports pain level as 3 on a scale of 1 to 10

Heart rate 72 beats per minute

Respiratory rate 22 per minute with even unlabored respirations

Coughed up 5 mL yellow sputum

Headache in frontal area

Answer and Explanation

Correct Answer : C,D,E

A. Assistive personnel reports the patient walks with a limp: This is secondhand information (reported by UAP), not directly observed by the nurse.

B. Patient reports pain level as 3 on a scale of 1 to 10: Pain is subjective data because it is based on the patient's self-report.

C. Heart rate 72 beats per minute: Heart rate is measured by the nurse, making it objective data.

D. Respiratory rate 22 per minute with even unlabored respirations: The nurse directly observes and measures respiratory rate, making it objective data.

E. Coughed up 5 mL yellow sputum: The nurse can observe and quantify the sputum (color and volume), making it objective data.

F. Headache in frontal area: A headache is subjective data because only the patient can describe it.

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Correct Answer is B

Explanation

A. It serves as a reminder of human growth and development across the life span: Maslow’s hierarchy focuses on prioritizing needs, not general growth and development.

B. It helps in prioritizing nursing diagnoses and care: Maslow’s hierarchy is used to prioritize patient needs, ensuring physiological needs (oxygen, fluid, nutrition) come first before psychological and self-actualization needs.

C. It outlines the basic psychological needs that people have when they are hospitalized and feel anxiety: Maslow includes psychological needs, but its primary purpose is prioritizing all human needs, including physiological ones.

D. It is a framework for thinking critically: While it aids in clinical decision-making, critical thinking encompasses broader concepts beyond Maslow’s hierarchy.

A. patient's nursing problem B. interventions carried out to meet the patient's needs C. patient's medical problem D. the patient's response to the intervention carried out

Correct Answer is B

Explanation

A. Patient's nursing problem: Nursing problems are identified in assessments, not the actual care documentation.

B. Interventions carried out to meet the patient’s needs: Documentation should include interventions, the time they were performed, and the caregiver’s signature for legal and professional accountability.

C. Patient’s medical problem: Medical problems are diagnosed by physicians, while nurses document care interventions related to nursing diagnoses.

D. The patient's response to the intervention carried out: While patient responses should be documented, this question focuses on recording interventions, not patient reactions.

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The nurse is documenting patient data. Which of the following should the nurse document under objective data? (select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

How is Maslow's Hierarchy of Human Needs used by nurses in a clinical setting?

Correct Answer is B

Explanation

Documenting the type of interventions carried out, the time care was given, and the signature of the care giver results in recording:

Correct Answer is B

Explanation

Understanding that health care personnel must respect the confidentiality of patients' records, the nurse:

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In which step of the nursing process do nurses look at outcomes?

Patient health care records are:

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