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The nurse is caring for a client who has been admitted to the hospital with abdominal pain and is suspected to have appendicitis. What data obtained is considered objective data?
- A. Bowel sounds hypoactive in the right lower quadrant
- B. Complaints of pain when right lower quadrant palpated
- C. Client states that the pain began 3 hours ago
- D. Client states feeling nauseated.
Correct Answer: A
Rationale: Objective data are facts obtained through observation, physical examination, and diagnostic testing. When assessing blood pressure or heart rate, or examining results from urinalysis, the nurse is obtaining objective data. The other answers are examples of subjective data.
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The nurse is assessing a client and determines that the vital signs are not within normal range for the client. With the results of the objective data being abnormal, what does the nurse document these findings as?
- A. Symptoms
- B. Subjective data
- C. Physical assessment
- D. Signs
Correct Answer: D
Rationale: When objective data are abnormal, they are called signs. Symptoms refer to feelings of discomfort felt by the client. Subjective data is what the client states to the nurse. Physical assessment is a general term used regarding the assessment of the client.
Which of the following are statements clients make about how they feel?
- A. Objective data
- B. Cultural data
- C. Cognitive data
- D. Subjective data
Correct Answer: D
Rationale: Subjective data include statements clients make about what they feel. Objective data are facts obtained through observation, physical examination, and diagnostic testing. Cultural data include cultural background and health beliefs.
The LPN observes the RN performing an assessment of the abdomen. The RN is lightly touching the client's abdomen and feeling it with the hands and fingertips. What assessment techniques is the LPN aware that the RN is using?
- A. Inspection
- B. Palpation
- C. Percussion
- D. Auscultation
Correct Answer: B
Rationale: Palpation is assessing the characteristics of an organ or body part by touching and feeling it with the hands or fingertips. Inspection is the systematic and thorough observation of the client and specific areas of the body. Percussion is a tapping of a portion of the body to determine if there is tenderness or to elicit sounds that vary according to the density of underlying structures. Auscultation means listening with a stethoscope for normal and abnormal sounds.
The nurse is caring for an older adult client who has recently been admitted and is performing a physical assessment. What test can the nurse perform to obtain a baseline cognitive function?
- A. Mini-Cog
- B. Neurovascular assessment
- C. Cardiovascular assessment
- D. Pupillary response
Correct Answer: A
Rationale: When performing a physical assessment for an older client, ascertain a baseline cognitive function level at onset of interview. The Mini-Cog is a quick and simple four-question method. Neurovascular and cardiovascular assessment and pupillary response are not specific assessment techniques to assess cognitive function.
The client comes to the clinic and says to the nurse, 'I am coming in today to see the doctor because I started having diarrhea 2 days ago and am going six to eight times per day.' How would the nurse document this statement?
- A. Concern: Client is afraid of becoming dehydrated due to amount of diarrhea.
- B. Problem: Client is having diarrhea at least six to eight times per day.
- C. The client is having diarrhea and wants to see the physician.
- D. Chief complaint: 'Diarrhea began 2 days ago and having six to eight stools per day.'
Correct Answer: D
Rationale: The chief complaint is the current reason the client is seeking care. 'Concern' is not a relevant response and is not what the client stated. 'The client is having diarrhea and wants to see the physician' is vague and does not give enough information. 'Problem: Client is having diarrhea' is not appropriate, and not informative documentation.