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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Diarrhea: Diarrhea is not a common adverse effect of clozapine. Gastrointestinal symptoms may occur with some antipsychotics, but diarrhea is not a primary concern with clozapine therapy.
B. Hypoglycemia: Clozapine is more commonly associated with hyperglycemia and increased risk of diabetes mellitus, rather than hypoglycemia. Blood glucose monitoring may be needed in clients at risk.
C. Agranulocytosis: Clozapine can cause severe neutropenia or agranulocytosis, which increases the risk of infection. Regular monitoring of white blood cell counts is essential, and any signs of infection should prompt immediate evaluation.
D. Urinary frequency: Urinary frequency is not a typical adverse effect of clozapine. Anticholinergic effects like urinary retention are more commonly associated with this medication, rather than increased frequency.
Correct Answer is B
Explanation
A. "I should expect my tears to turn a red color after using the eye drops.": Timolol does not cause red discoloration of tears. Redness of the eye may indicate irritation, allergy, or another adverse effect, so the client should report persistent redness rather than expect it as normal.
B. "I will put pressure on the corner of my eye after using the eye drops.": Applying gentle pressure to the nasolacrimal duct (inner corner of the eye) after instilling timolol reduces systemic absorption and potential systemic side effects, such as bradycardia or hypotension. This technique demonstrates proper administration and understanding of safety precautions.
C. "The drops should be placed in the center of my eye.": Eye drops should be instilled into the lower conjunctival sac, not directly onto the center of the cornea, to reduce irritation and maximize absorption. Placing drops on the cornea can cause discomfort and reduce effectiveness.
D. "These drops will improve my cloudy vision.": Timolol lowers intraocular pressure but does not restore vision or improve cloudiness caused by glaucoma. The goal of therapy is to prevent progression of vision loss, not to reverse existing damage.
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