A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?
Edema
Heart Rate
Chills
Pallor
The Correct Answer is C
A. Edema:
Edema refers to the presence of swelling caused by an accumulation of fluid. While the nurse can observe and measure edema, the sensation of swelling itself is subjective and based on the client's perception.
B. Heart Rate:
Heart rate is an objective measure of the number of heartbeats per minute. It can be measured and observed by the healthcare provider, making it an objective data point.
C. Chills
Subjective data refers to information that is based on the client's personal experiences, perceptions, and feelings. Chills, which describe a feeling of coldness often associated with shivering, are a subjective symptom that the client experiences.
D. Pallor:
Pallor refers to an unusually pale or white skin color. While the nurse can observe and assess the color of the skin, the client's perception of pallor is subjective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Performs auscultation between meals:
Auscultating bowel sounds between meals is suitable as it allows for better detection of bowel sounds when digestion is not actively occurring.
B. Clamps the Naso Gastric tube during auscultation
Clamping the Naso Gastric (NG) tube during auscultation is appropriate. The NG tube when unclamped allows the free passage of air and fluid through the gastrointestinal tract. This could interfere with the natural sounds produced by the movement of air and fluid in the intestines, potentially leading to inaccurate assessment of bowel sounds.
C. Palpates the abdomen prior to performing auscultation:
Palpating the abdomen before auscultation may interfere with normal bowel sounds
D. Auscultates bowel sounds for 3 to 5 min:
Auscultating bowel sounds for a sufficient duration (3 to 5 minutes) is appropriate to comprehensively assess the presence, frequency, and character of bowel sounds.
Correct Answer is D
Explanation
A. He has an electrical burn, which caused coagulation of some tissues:
This response provides more detailed information about the nature of the electrical burn, mentioning tissue coagulation. However, it may be more information than the family needs at this point, and it's important to balance providing information with respecting the client's privacy.
B. He is doing well, although he might be in the hospital for some time:
While this response aims to reassure the family about the client's general status, it might not be entirely accurate or provide specific information about the client's condition. It's important to be transparent while respecting the client's privacy.
C. He does not appear to have much damage and should be fine soon:
This response may provide a sense of reassurance to the family, but it might oversimplify the situation. It's important to provide accurate and honest information while respecting the client's privacy.
D. He has an electrical burn. He is stable, and we will update you with any changes:
This response acknowledges the type of injury, assures the family that the client is stable, and communicates a commitment to keeping the family informed of any changes. It strikes a balance between providing some information and maintaining the client's privacy and confidentiality.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.