Which assessment is subjective as it relates to the musculoskeletal system?
Vital signs: Temperature 98.2, Pulse 92 bpm, Respirations 18/min, BP 136/84 mm Hg, Oximeter reading 98%.
Patient has been taking nonsteroidal anti-inflammatory drugs (NSAIDs) for his right elbow pain.
Pain 7 to 8.
Grimacing and holding affected body part.
The Correct Answer is C
Choice A reason: Vital signs are objective, measurable data, not specific to musculoskeletal assessment or subjective experience. Pain, a subjective report, better fits the question. Assuming vital signs are subjective risks misclassifying data, leading to errors in prioritizing patient-reported symptoms like pain, critical for musculoskeletal care planning and intervention.
Choice B reason: Taking NSAIDs is a factual history, not a subjective assessment. Subjective data, like pain severity, reflect patient experience. Assuming medication use is subjective misaligns with assessment principles, risking neglect of patient-reported symptoms like pain, essential for evaluating musculoskeletal conditions and guiding effective pain management strategies.
Choice C reason: Pain rated 7 to 8 is subjective, based on the patient’s personal experience, central to musculoskeletal assessment for conditions like arthritis or injury. This guides pain management, like adjusting NSAIDs. Accurate identification ensures patient-centered care, addressing discomfort and improving function, critical for musculoskeletal health outcomes.
Choice D reason: Grimacing and holding a body part are objective, observable signs, not subjective reports. Pain severity, reported by the patient, is subjective. Assuming grimacing is subjective risks misclassification, potentially overlooking patient-reported pain levels, critical for tailoring interventions like analgesics in musculoskeletal assessment and care planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Normal blood pressure is <120/<80 mmHg, far below 148/92 mmHg, which is stage 2 hypertension per AHA guidelines. Assuming normal misclassifies the reading, risking untreated hypertension, leading to complications like stroke or heart failure. Accurate classification ensures proper management with lifestyle changes or medications.
Choice B reason: Stage 1 hypertension is 130-139/80-89 mmHg, lower than 148/92 mmHg, which is stage 2. Misclassifying as stage 1 underestimates severity, potentially delaying aggressive treatment like dual antihypertensives. Correct staging ensures timely intervention, critical for preventing cardiovascular damage in patients with elevated blood pressure readings.
Choice C reason: Stage 2 hypertension, per AHA, is ≥140/≥90 mmHg, matching 148/92 mmHg. This requires immediate lifestyle changes and likely medications to prevent cardiovascular events. Accurate classification guides treatment, ensuring blood pressure control, reducing risks of stroke, heart attack, or kidney damage in patients with significant hypertension.
Choice D reason: Elevated blood pressure is 120-129/<80 mmHg, below 148/92 mmHg, which is stage 2 hypertension. Assuming elevated underestimates the condition, risking inadequate intervention and progression to organ damage. Correct classification ensures appropriate management, critical for controlling hypertension and preventing long-term complications in affected patients.
Correct Answer is D
Explanation
Choice A reason: Providing a blueprint for patient-centered care describes the nursing process (assessment, diagnosis, planning, implementation, evaluation), guiding systematic care delivery. This is integral, unlike prescribing medications, a physician’s role. Assuming this is not part risks misunderstanding the process, critical for structured, effective nursing care in complex patient scenarios.
Choice B reason: Holistic care enhancing outcomes is central to the nursing process, addressing physical, emotional, and social needs through its steps. This contrasts with prescribing, which is medical. Assuming this is not part misaligns with the process’s purpose, risking fragmented care and reduced effectiveness in patient-centered nursing practice.
Choice C reason: A problem-solving approach for complex clients defines the nursing process, using data to address multifaceted needs systematically. Unlike prescribing, it’s a nursing responsibility. Assuming this is not part undermines the process’s role, risking ineffective care planning and interventions critical for managing complex patient conditions in clinical settings.
Choice D reason: Developing medication prescriptions is a physician’s role, not part of the nursing process, which focuses on assessment, diagnosis, planning, implementation, and evaluation. Nurses administer or educate about medications but don’t prescribe. This distinction ensures role clarity, preventing scope-of-practice errors and supporting collaborative, patient-centered care in healthcare settings.
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