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 C

Explanation

A. While considering staff morale is important, it should not be the primary factor in making patient assignments. The focus should be on patient safety and care needs.

B. While experience is a valuable asset, it's not always fair or practical to assign the most complex patients to one nurse. It's essential to consider the overall workload and skill mix of the nursing staff.
C. This is the most crucial factor in making patient assignments. Patients with unstable conditions or complex care requirements should be assigned to nurses with the appropriate skills and experience.
D. The charge nurse's personal comfort should not influence patient assignments. The primary goal is to ensure safe and effective patient care.

A. Provide the client time during the day for meditation. B. Suggest relaxation techniques for the client. C. Ensure the client can select a nutritious diet. D. Educate the client on recommended health screenings for their age. E. Assist the client to maintain relationships with their family. F. Promote ideas to encourage the client to stay active.

Correct Answer is ["A","B","C","D","F"]

Explanation

A. Meditation can be a valuable intervention for improving overall well-being, including physical health, by reducing stress and promoting relaxation. While its primary benefits are often psychological and emotional, reducing stress can also have positive effects on physical health, such as lowering blood pressure and improving heart health.
B. Suggesting relaxation techniques, such as deep breathing exercises, progressive muscle relaxation, or guided imagery, is a beneficial intervention. These techniques can help manage stress, lower blood pressure, and improve overall physical health. Incorporating relaxation methods can enhance the
client’s sense of well-being and support physical health by mitigating the effects of stress on the body.
C. Ensuring that the client has access to and can select a nutritious diet is a fundamental aspect of promoting physical well-being. A balanced and nutritious diet supports overall health, helps in maintaining a healthy weight, and provides essential nutrients for bodily functions.
D. Educating the client about recommended health screenings for their age is crucial for early detection and prevention of diseases. Regular screenings can help identify potential health issues before they become serious, contributing to better long-term physical health.
E. While maintaining relationships with family is important for emotional and psychological well-being, it is not a direct intervention specifically aimed at improving physical health. Social support and strong relationships can indirectly benefit physical health by reducing stress and improving overall quality of life, but this is not a direct physical health intervention.
F. Promoting physical activity is a direct and effective intervention for improving physical well-being. Regular exercise contributes to cardiovascular health, muscle strength, flexibility, and overall physical fitness. Encouraging clients to stay active supports their physical health and helps prevent or manage chronic conditions.

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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.)

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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.)