You are assessing a client who complains of chest pain. Which of the following is an example of subjective data?
Client's respiratory rate is 28 breaths per minute.
Client states. My chest feels right and hurts when I breathe deeply
Client's ECG results show abnormal activity.
Client is holding their chest and appears anxious
The Correct Answer is B
A. Client's respiratory rate is 28 breaths per minute: This is objective data because it can be measured and verified by the nurse. Vital signs provide quantifiable information about the client’s physiological status.
B. Client states, "My chest feels tight and hurts when I breathe deeply": This is subjective data because it reflects the client’s personal experience and perception of symptoms. Subjective data cannot be measured directly and must be reported by the client.
C. Client's ECG results show abnormal activity: ECG findings are objective data because they are measurable, recorded, and interpreted using standardized criteria. They provide concrete evidence of cardiac activity.
D. Client is holding their chest and appears anxious: This is also objective data because it is observable and measurable behavior. The nurse can see and document these actions without relying on the client’s personal report.
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Related Questions
Correct Answer is D
Explanation
A. Activation of the parasympathetic nervous system: The parasympathetic system promotes “rest and digest” responses, including slowed heart rate and relaxation, which are opposite to the observed acute stress signs.
B. Decreased blood flow to muscles: During acute stress, blood flow to muscles actually increases to prepare for rapid physical response. Decreased perfusion would impair the body’s ability to respond to stress.
C. Release of insulin: Insulin primarily regulates blood glucose levels. During acute stress, insulin secretion is often suppressed to allow elevated glucose for energy, making this unrelated to the immediate stress response.
D. Activation of the sympathetic nervous system: The sympathetic nervous system triggers the “fight or flight” response, leading to tachycardia, rapid respirations, increased muscle tone, and mobilization of energy stores. These physiological changes align with the signs observed in acute stress reactions.
Correct Answer is A
Explanation
A. Use positive facial expressions and open-ended questions: Active listening in pediatrics involves creating a supportive environment through nonverbal cues and open-ended questions that encourage the child to express thoughts and feelings at their own pace. This approach fosters trust and communication.
B. Focus on completing the assessment quickly: Rushing the assessment may increase the child’s anxiety and discourage disclosure. Active listening requires patience and attention rather than prioritizing speed.
C. Assure the child that their feelings are not important: Minimizing or dismissing the child’s emotions undermines trust and can exacerbate emotional distress. Recognizing feelings as valid is essential for effective communication.
D. Directly ask the child to explain their feelings: Direct questioning may feel confrontational or overwhelming, especially if the child is hesitant. Open-ended questions and supportive cues are more effective for eliciting responses in a non-threatening way.
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