A nurse is documenting data collection findings on a client. Which of the following entries should the nurse identify as subjective data? (Select All that Apply.)

Client reports the rash on their back is itchy

Client reports nausea following administration of pain medication.

Client has a raised, red rash on their upper back.

Client reports dull, aching pain in lower right calf.

Client's oral temperature is 38.4° C (101.2° F).

Answer and Explanation

Correct Answer : A,B,D

A.   This entry reflects the client’s personal experience and perception of the rash. It is not measurable and relies on the client’s description.

B.   This statement is also based on the client’s experience and feelings about their condition after taking medication. It is a personal report and not an observable finding.
C.   This is an observation made by the nurse. The description of the rash is measurable and can be documented as a physical finding.
D.   Similar to options A and B, this entry describes the client’s perception of pain. It is a personal
experience that cannot be directly measured.
E.   This is a measurable finding obtained through a thermometer. It provides concrete evidence of the
client’s condition and does not rely on the client’s report.

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Correct Answer is A

Explanation

A. The Code of Ethics for nurses emphasizes the importance of confidentiality and respecting patient privacy. Accessing a client's medical record without a legitimate reason or involvement in their care violates ethical principles regarding patient rights and privacy.
B. Evidence-based practice involves integrating the best available research with clinical expertise and patient values to inform decision-making. While this standard is important for providing high-quality care, it does not directly relate to the unauthorized access of a client's medical record.
C. Collaboration in nursing refers to working together with other healthcare professionals and the patient to provide coordinated care. While accessing a medical record without involvement in care does not align with collaborative practice, it is not the primary standard being violated in this situation.
D. The quality of practice standard focuses on providing high-quality care and improving patient outcomes. While unethical behavior, such as accessing records without proper justification, could impact quality, this option does not specifically address the violation related to confidentiality and privacy.

A. Hearing loss is considered a development factor that has minimal effect on nurse-client communication. B. Clients who have developmental deficits are less distracted by environmental noises than client who do not have these deficits. C. Nurses might focus on a client's physiological needs over psychosocial needs when communicating during care. D. Nurses caring for clients experiencing a highly emotional situation report that communication is rarely affected.

Correct Answer is D

Explanation

A. Hearing loss is a significant factor that can significantly impact nurse-client communication. Clients with hearing loss may have difficulty understanding what is being said, leading to misunderstandings and frustration.
B. Clients with developmental deficits may be more sensitive to environmental noises and distractions, which can make it difficult to focus on communication.
C. This can be a significant barrier to effective communication, as it can lead to neglecting the client's emotional and psychological needs. It's important for nurses to be aware of this tendency and to make a conscious effort to address both the physical and emotional needs of their clients.
D. Emotional factors can significantly affect communication. When clients are experiencing a highly emotional situation, they may be more likely to become overwhelmed, anxious, or defensive, which can make it difficult to communicate effectively.

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A nurse is documenting data collection 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 looks up information in a client's medical record but is not involved in the care of the client. The nurse is violating which of the following standards of professional performance?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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