A nurse is documenting assessment findings on a client. Which of the following entries should the nurse identify as subjective data?
(Select All that Apply.)
Client reports dull, aching pain in lower right calf.
Client reports nausea following administration of pain medication.
Client's oral temperature is 38.4° C (101.2° F).
Client reports the rash on their back is itchy.
Client has a vesicular rash on their upper back.
Correct Answer : A,B,D
A. This is subjective data. The description of pain as "dull" and "aching" is based on the client's personal experience and cannot be measured directly by the nurse. Pain is a subjective symptom because it varies from person to person and is reported by the patient.
B. This is subjective data. Nausea is a feeling or sensation reported by the client and is based on their personal experience. The nurse relies on the client's report to assess this symptom, as it cannot be directly observed or measured.
C. This is objective data. The temperature reading is a measurable, quantifiable fact that can be directly observed and recorded by the nurse using a thermometer. It provides concrete evidence of the client's condition.
D. This is subjective data. Itchiness is a sensation reported by the client and is based on their personal experience. The nurse cannot measure itchiness directly; they rely on the client’s description to understand the symptom.
E. This is objective data. The presence of a vesicular rash is an observable finding that the nurse can see and document. It is a physical characteristic that can be directly assessed and recorded.
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Related Questions
Correct Answer is D
Explanation
A. While clinical judgment is essential in decision-making, it is based on experience and intuition. While valuable, it alone is not sufficient for evidence-based decision-making.
B. Critical thinking is a vital component of clinical decision-making, but it focuses on analyzing information and evaluating options. It's part of the process but doesn't encompass the entire evidence- based decision-making framework.
C. This is a visual tool used to organize information and identify relationships. It's a helpful aid in decision-making but not the core component.
D. This involves using critical thinking, knowledge, and experience to analyze patient data, consider options, and make decisions. It is the process of applying evidence to patient care and is therefore the most accurate answer.
Correct Answer is B
Explanation
A. Advocacy involves protecting the client's rights and interests. While the nurse is acting in the client's best interest by assessing and reporting the error, the primary action here is taking responsibility.
B. Accountability is taking responsibility for one's actions and their consequences. By admitting the medication error, assessing the client, notifying the provider, and completing an incident report, the nurse is demonstrating accountability for their actions.
C. Confidence is believing in one's abilities. While confidence is important in nursing, it is not the primary characteristic displayed in this scenario.
D. Fairness involves treating everyone equally. This is not directly related to the nurse's actions in this case.
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