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A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
- A. Complains of pruritus.
- B. Is experiencing erythema.
- C. Appears to be experiencing pruritus.
- D. Has a generalized rash.
Correct Answer: A
Rationale: Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Pruritus is the only subjective assessment finding. All other options are examples of objective data.
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During a physical assessment the nurse notes a patient has a lack of appetite resulting in an inability to eat. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Asthenia
- C. Anorexia
- D. Ecchymosis
Correct Answer: C
Rationale: Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions.
When assessing a patient the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient into a sitting position the patient is able to breathe more easily. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Jaundice
- D. Orthopnea
Correct Answer: D
Rationale: Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems.
The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan?
- A. Health history
- B. Review of systems
- C. Family history
- D. Nursing assessment
Correct Answer: D
Rationale: The nursing assessment is the critical step in forming the nursing care plan.
A health care provider documents that a patient has a scleral icterus. What is the cause of this coloring?
- A. Bilirubin
- B. Hemoglobin
- C. Serum potassium
- D. Serum magnesium
Correct Answer: A
Rationale: Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body.
The nurse is collecting data during an initial assessment. What can be seen heard measured or felt and is objective?
- A. Symptom
- B. Observation
- C. Sign
- D. Assessment
Correct Answer: C
Rationale: A sign can be seen, heard, measured, or felt.