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 C
Explanation
A. Withdraw dose of regular insulin: Withdrawing the regular insulin dose is performed after the air has been injected into both vials and the NPH insulin has been drawn up if using the “clear before cloudy” technique. Doing this first would risk disrupting the proper sequence and potentially contaminating the insulin.
B. Inject air into the vial of regular insulin: Air must be injected into the regular insulin vial before withdrawing the medication, but this step is performed after first injecting air into the NPH vial according to the standard procedure for mixing insulins. Starting with the regular insulin vial would not follow the recommended order.
C. Inject air into the vial of NPH insulin: Injecting air into the NPH insulin vial first is the initial step when preparing a mixed insulin dose. This step equalizes pressure inside the vial, allowing for easier withdrawal later, and follows the correct sequence of “air into cloudy first, then clear,” which prevents contamination of the regular insulin.
D. Withdraw dose of NPH insulin: Withdrawing NPH insulin is done after the regular insulin has been drawn into the syringe to maintain the correct “clear before cloudy” technique. Doing this first could result in accidental mixing or contamination of the regular insulin.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Rationale
• Genitourinary findings: Intermittent sensations of "squeezing or spasm" in the bladder or urinary tract are typical in multiple sclerosis due to autonomic nervous system involvement and demyelination affecting bladder control. These symptoms are less common in ALS, which primarily affects motor neurons without early autonomic involvement.
• Report about gait: Episodes of leg weakness and balance issues can occur in both ALS and MS. ALS causes progressive motor weakness affecting gait due to upper and lower motor neuron degeneration. MS can cause intermittent gait disturbances from demyelination in the central nervous system, often with exacerbations and remissions.
• Vision disturbance: Intermittent double vision is consistent with MS, reflecting demyelination of cranial nerves or the optic pathways. Visual symptoms, including diplopia or optic neuritis, are hallmark early signs of MS. ALS typically does not involve vision, making this symptom specific to MS.
• Energy level: Fatigue lasting more than 4 months aligns with MS, which frequently causes persistent fatigue due to both neurological dysfunction and immune-mediated inflammation. ALS may lead to fatigue later in disease progression, but early chronic fatigue is more characteristic of MS.
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