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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The MDS forms are used to comprehensively document various aspects of a resident's health, including their cognitive abilities, physical health, functional status, and other relevant factors. This data is essential for creating individualized care plans, ensuring compliance with regulations, and monitoring changes in residents' conditions over time.
B. The MDS forms are not completed by the provider each month. Instead, they are typically completed at specific intervals, such as upon admission, quarterly, and when there are significant changes in the resident's condition.
C. The MDS forms themselves do not come with an analysis of prescribed medications. While medication management is an important aspect of resident care, the MDS focuses on broader assessments of health and functional status rather than detailed medication analysis.
D. The MDS forms are not faxed to health care providers. Instead, the MDS documentation is used internally within the facility for care planning and regulatory compliance, and the data may be submitted electronically to regulatory bodies as required.
Correct Answer is C
Explanation
A. Hospice care focuses on providing comfort and quality of life rather than curative treatment. The goal is to manage symptoms and provide supportive care when a cure is no longer possible. Therefore, hospice care typically does not include aggressive treatments.
B. Hospice care is generally initiated when a prognosis indicates that the client is expected to have 6 months or less to live if the illness runs its usual course. The 2-year timeframe mentioned here is too long for standard hospice eligibility, which is based on a more immediate prognosis of terminal illness.
C. Hospice care services often include respite care, which provides caregivers with temporary relief from their caregiving duties. This respite allows caregivers to take personal time, recharge, and manage their own needs, which is an important aspect of supporting those who are caring for terminally ill patients.
D. While hospice care does involve communication with the family about the client's care and condition, the primary focus of hospice care is on providing comfort and support to the patient.
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