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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Set a goal to maintain blood glucose levels within normal range: In the planning phase, establishing measurable and achievable goals is the priority. Setting a target for blood glucose guides the development of interventions and provides a benchmark for evaluating the effectiveness of care.
B. Document the patient's blood glucose readings: Documentation is part of the implementation and evaluation phases. While important for tracking trends, it does not establish the direction of care or plan interventions.
C. Teach the patient about carbohydrate counting: Patient education is an intervention that supports achieving the goal, but it cannot be implemented effectively without first defining the desired outcome.
D. Administer insulin as prescribed: Administering insulin is an implementation action. While critical for management, it is guided by the plan and goals set during the planning phase, rather than being the initial planning step.
Correct Answer is A
Explanation
A. Administer oxygen therapy to improve oxygen saturation levels: According to Maslow’s hierarchy, physiologic needs such as oxygenation take highest priority. Hypoxemia compromises cellular metabolism and can rapidly become life-threatening if not corrected. Immediate oxygen therapy supports airway and breathing, making it the nurse’s first action.
B. Provide emotional support to the patient: Emotional reassurance addresses psychosocial needs, which are important but secondary to physiologic stability. A patient experiencing shortness of breath requires correction of oxygen imbalance before anxiety can be effectively managed. Psychological support is more effective once oxygenation improves.
C. Discuss the patient's concerns about their safety in the hospital: Safety concerns fall under Maslow’s safety and security needs. While relevant, these needs are prioritized after physiologic needs such as adequate oxygen delivery. Addressing safety without stabilizing breathing places the patient at continued risk.
D. Assist the patient in meeting their self-actualization needs: Self-actualization represents the highest level of Maslow’s hierarchy and is only addressed after all basic and psychological needs are met. A patient with respiratory compromise is not physiologically stable enough for this level of intervention.
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