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Which of these assessment findings should a nurse record as subjective?

A.

Hives.

B.

Itching.

C.

Vomiting.

D.

Abdominal distension.

Answer and Explanation

The Correct Answer is B

This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the

patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.

For example:

Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.

Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.

Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.

Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:

  • Hives: No hives or rashes on the skin are normal.
  • Vomiting: No vomiting or nausea are normal.
  • Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).


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Related Questions

Correct Answer is B

Explanation

This indicates that the client has a fluid volume deficit, which is consistent with the signs and symptoms of low urine output, weight gain, irritability, and headache. The normal range for serum osmolality is 275 to 295 mOsm/Kg.

Choice A is wrong because hemoglobin 15.3 mg/dL is within the normal range of 12 to 18 mg/dL and does not correlate with fluid imbalance.

Correct Answer is D

Explanation

This question evaluates the client’s understanding of the most important infection control measure for hepatitis A, which is hand hygiene. Hepatitis A is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person’s feces.

Washing hands after using the toilet can prevent the spread of the virus to others and to oneself.

Choice A is wrong because eating raw shellfish is not a risk factor for hepatitis A unless the shellfish is contaminated with the virus from polluted water.

Choice B is wrong because cooking pork products does not affect hepatitis A transmission, as the virus is not found in pork or other meats.

Choice C is wrong because traveling out of the country is not a risk factor for hepatitis A unless the destination has poor sanitation and hygiene conditions.

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