During an assessment, a client who is not very talkative appears pale, diaphoretic, and restless in the bed, and says "leave me alone." Which subjective data should the nurse document?
1. Restlessness
2. "Leave me alone"
3. Not talkative
4. Pale and diaphoretic
Correct Answer: 2
Rationale 1: Restlessness is observable so it is not subjective data.
Rationale 2: Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the client's sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations.
Rationale 3: Not being talkative is observable so it is not subjective data.
Rationale 4: Paleness with diaphoresis is observable so this is not subjective data.
You might also like to view...
A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question?
a. Increase intravenous fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes STAT.
Which of the following is a hallmark of the scientific method?
A) Rigorous B) Holistic C) Systematic D) Flexible
The Centers for Disease Control and Prevention (CDC) have defined AIDS-related wasting syndrome as _____ loss of >10% of body weight in 1 month _____ chronic diarrhea, weakness, or fever
a. involuntary; without b. voluntary; without c. involuntary; with d. voluntary; with
A nursing student was ill when the class toured the learning resource center (LRC). What independent action should the student take?
a. Perceive it as a missed opportunity. b. Ask the librarian if a self-guided audiotape tour is available. c. Ask to see another student's notes about the tour. d. Report his or her unawareness to the instructor of LRC features.