A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

The patient has low blood pressure.

The patient is short of breath.

The patient has wound drainage.

The patient reports feelings of fatigue.

Answer and Explanation

The Correct Answer is D

A: Low blood pressure is an objective finding that can be measured directly.

B: Shortness of breath is a subjective symptom reported by the patient.
C: Wound drainage is an objective finding that can be observed directly.

D: Feelings of fatigue are subjective symptoms reported by the patient, reflecting their personal experience rather than directly observable physical signs.

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Correct Answer is B

Explanation

A: Anisocoria refers to a condition where the pupils are of unequal sizes, which is not related to focusing ability.

B: Accommodation response involves the ability of the eye to change focus from distant to near objects, demonstrating the flexibility of the lens which is exactly what the instruction aims to test.
C: Direct pupil response relates to pupil constriction in response to light, not changes in focal distance.
D: Consensual reflex also refers to the reaction of both pupils to light and would not be assessed through changes in focal distance.

A. The patient's spouse reports experiencing marital issues. B. The patient reports a history of chest pain. C. The patient complains of chronic constipation. D. The patient verbalizes anxiety about hospitalization.

Correct Answer is A

Explanation

A. The patient's spouse reporting experiencing marital issues is a perfect example of secondary information as it comes from someone other than the patient and might affect the patient's care or emotional well-being indirectly.
B. The patient reports a history of chest pain, is an example of primary information. This is because the patient directly reports the symptoms of their health condition.
C. The patient complaining of chronic constipation is an example of primary information. This is because the patient is directly reporting their own health condition.

D. The patient verbalizes anxiety about hospitalization is also primary information, directly provided by the patient concerning their feelings about the current care environment.

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A nurse is performing an admission assessment on a patient. When collecting objective and subjective data, the nurse identifies subjective data as

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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