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During an admission assessment the nurse collects objective and subjective data. What is an example of subjective data?
- A. The patient complains of nausea.
- B. The patient is vomiting.
- C. The patient experiences tachycardia.
- D. The patient is pacing the halls.
Correct Answer: A
Rationale: Subjective data are the verbal statements provided by the patient. Statements about nausea and descriptions of pain, fatigue, and anxiety are examples of subjective data. Complaining of nausea is an example of subjective data. All other options are examples of objective data.
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A nurse is formulating a patient problem. What is an example of an appropriately written patient problem?
- A. Risk for impaired skin integrity related to physical immobilization
- B. Physical immobilization secondary to risk for impaired skin integrity
- C. Risk for impaired skin integrity related to diagnosis of decubitus ulcers
- D. Physical immobilization secondary to decreased cognitive ability
Correct Answer: A
Rationale: Risk for impaired skin integrity related to physical immobilization is the only appropriately written patient problem. All other options are not listed as NANDA-I approved patient problems.
What objective data should the nurse include after a patient assessment?
- A. Headache of 3 days' duration
- B. Severe stomach cramps
- C. Flatulence
- D. Anxiety
Correct Answer: C
Rationale: Objective data are observable and measurable by people other than the patient.
When the nurse is prioritizing care during the planning phase of the nursing process what is the guiding framework?
- A. Primary
- B. Secondary
- C. Unreliable
- D. Biased
Correct Answer: B
Rationale: Secondary sources include family members.
What organized approach might the nurse use when performing a complete physical examination?
- A. Maslow's hierarchy of needs
- B. A head-to-toe assessment
- C. Subjective data collection
- D. Objective data collection
Correct Answer: B
Rationale: A head-to-toe format provides a systematic approach.
What is an example of an appropriate Patient problem?
- A. Impaired skin integrity
- B. Skin breakdown noted
- C. Turn patient every 2 hours
- D. The patient has scabies on his back
Correct Answer: A
Rationale: Impaired skin integrity' is an example of a patient problem. 'Skin breakdown noted' is an example of a charting entry, 'turn patient every 2 hours' is a nursing intervention, and 'scabies' is a medical diagnosis.