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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Advocacy involves supporting and defending a patient's interests. While evaluating pain medication is important, it doesn't directly demonstrate advocacy.
B. By checking the effectiveness of pain medication, the nurse is fulfilling their responsibility to provide optimal care and manage patient pain.
C. Confidence is important for nurses, but it's not directly demonstrated in this specific action.
D. Fairness is a broader concept related to treating all patients equitably. Evaluating pain medication is a standard of care for all patients experiencing pain, regardless of their background or circumstances.

A. Confirming that a client appears competent to consent to a surgical procedure. B. Verifying that a client voluntarily gave consent to a surgical procedure. C. Witnessing a client consent for a surgical procedure. D. Explaining the steps of a surgical procedure to a client.

Correct Answer is D

Explanation

A. This is a professional and important action. Ensuring that a client is competent to consent means that the nurse is verifying that the client understands the nature, purpose, risks, and benefits of the procedure. Competence to consent is a legal and ethical requirement, and it is part of the nurse’s role to support and facilitate the informed consent process.
B. This is also a professional and necessary action. It involves checking that the client’s consent is given freely, without coercion or undue pressure. This step ensures that the consent is valid and ethical. It is part of the nurse's responsibility to ensure that the consent process respects the client's autonomy.
C. The nurse as a witness is there to observe that the consent is signed by the client and that the client understands what they are consenting to. However, the nurse should not be the one explaining the procedure or the risks involved unless they are specifically trained and authorized to do so.
D. This is generally not considered professional behavior for a nurse unless they have specific training and authorization to provide detailed information about surgical procedures. Typically, detailed explanations of the procedure are provided by the surgeon or a qualified healthcare provider.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse checks a client to evaluate the effectiveness of a pain medication. Which of the following components of professionalism is the nurse demonstrating?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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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.)