Which information obtained during a history and physical examination should the nurse document as subjective data?

A. Asking closed-ended questions to direct the conversation: Closed-ended questions limit responses and can restrict the flow of information. Active listening involves open-ended questions that encourage the client to share more detailed thoughts and feelings.

B. Focus on typing notes while the client is speaking: Diverting attention to note-taking can signal disinterest and reduce the nurse’s ability to interpret verbal and nonverbal cues. Active listening requires full attention to the client.

C. Provide advice before the client has finished speaking: Interrupting with advice prevents the nurse from fully understanding the client’s perspective. Active listening involves allowing the client to express themselves completely before responding or offering guidance.

D. Maintain eye contact and nod to indicate understanding: Nonverbal cues such as eye contact, nodding, and facial expressions demonstrate attentiveness and understanding. These behaviors encourage the client to communicate openly and confirm that the nurse is actively listening.

A. Completing a follow-up focused assessment: Focused assessments require nursing judgment and clinical decision-making to identify changes in a client’s condition. This task cannot be delegated to UAP because it involves interpretation of findings and determining interventions.

B. Assessing a client's mental health status: Mental health assessments require specialized knowledge and critical thinking to evaluate mood, thought processes, and risk factors. UAPs do not have the training to perform these assessments safely or interpret the results.

C. Obtaining a client's vital weight: Measuring a client’s weight is a routine, noninvasive task that does not require nursing judgment. UAPs are trained to safely obtain and record vital weights, making this appropriate to delegate.

D. Obtaining a client's vital signs: Vital signs are standard, routine measurements that UAPs can reliably perform. Nurses can delegate this task while retaining responsibility for interpreting the results and making clinical decisions.

E. Assessing a client's medication history: Gathering medication history involves evaluating prescriptions, interactions, and adherence patterns. This requires nursing knowledge and critical thinking, so it should not be delegated to UAPs.