A nurse is documenting assessment findings for a client. Which of the following is an example of subjective data?
The client drank 240 mL of water at 0800.
The client's gait is steady while using a walker.
The client cries while answering questions.
The client points to a 6 on the visual analog pain scale.
The Correct Answer is D
A. The client drank 240 mL of water at 0800: This is objective data because it is a measurable and observable fact that can be verified by the nurse. Documentation of intake is based on direct observation rather than the client’s perception.
B. The client's gait is steady while using a walker: This is objective data as it is based on the nurse’s direct observation of the client’s physical performance. It can be measured or assessed without relying on the client’s personal experience.
C. The client cries while answering questions: Crying is an observable behavior, making it objective data. While it may indicate distress, the nurse is reporting what was seen rather than the client’s internal experience.
D. The client points to a 6 on the visual analog pain scale: This is subjective data because it reflects the client’s personal perception of pain, which cannot be independently measured or verified. Pain is inherently subjective, relying on the client’s self-report.
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Related Questions
Correct Answer is A
Explanation
A. Speak to a first-level manager about the social media post: Reporting the social media post to a first-level manager ensures that the situation is handled through proper administrative and professional channels. This protects client confidentiality, aligns with HIPAA regulations, and maintains professional accountability.
B. Gather additional information from other colleagues: Seeking additional information from peers may violate confidentiality and is not an appropriate method for addressing potential breaches of client privacy. The concern should be escalated through formal reporting channels rather than informal investigation.
C. Inform the client about the social media post: Directly informing the client may not be appropriate without guidance from administration or risk management, as it could complicate investigation or legal procedures. The issue should first be reported to management for proper handling.
D. Ask the colleague why the information was posted: Confronting the colleague directly could lead to defensiveness, workplace conflict, or compromised evidence. The appropriate first step is to report the concern to a supervisor rather than attempt immediate resolution with the colleague.
Correct Answer is D
Explanation
A. Administer a dose of fluoxetine to the client: Fluoxetine is an antidepressant and is not indicated for acute psychotic symptoms such as auditory hallucinations in schizophrenia. Antipsychotic medications, not SSRIs, are the standard treatment for managing hallucinations.
B. Avoid making eye contact with the client: Avoiding eye contact can be perceived as disengagement or disinterest, which may increase the client’s anxiety or mistrust. Therapeutic communication with appropriate eye contact helps establish rapport and conveys presence and support.
C. Request the client to lie down in a quiet room: Forcing the client to lie down may increase distress or feelings of loss of control. While a quiet environment can reduce stimuli, the intervention should be voluntary and focused on coping strategies rather than directives.
D. Encourage the client to listen to music: Listening to music can help distract the client from hallucinations and provide a coping mechanism to reduce distress. This intervention supports safety, comfort, and engagement without confrontation, aligning with therapeutic approaches for managing auditory hallucinations.
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