A nurse assisting with data collection of a client gathers both
subjective and objective data. Which finding would the nurse
document as subjective
... [Show More] data?
The client appears anxious. Blood pressure is 170/80 mm Hg.
Correct! The client states that he has a rash.
The client has diminished reflexes in the legs.
Rationale: The purpose of a physical assessment is to
collect both subjective and objective data. Subjective data,
collected during the health history, consist of information
that the client gives about himself or herself. Objective
data are obtained through physical examination and vital
signs measurements, what the nurse observes, and
laboratory study and diagnostic test results.
Test-Taking Strategy: Use the process of elimination.
Eliminate the comparable or alike options that include data
that the nurse would obtain during the physical
examination. Review the difference between subjective
and objective data if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Content Area: Health Assessment/Physical Exam
Question 2 1 / 1 pts
A nurse is reviewing the findings of a physical examination that
have been documented in a client’s record. Which piece of
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information does the nurse recognize as objective data?
The client is allergic to strawberries. The last menstrual period was 30 days ago. The client takes acetaminophen (Tylenol) for headaches.
A 1 × 2-inch scar is present on the lower right portion of the
abdomen.
Correct!
Rationale: Subjective data, collected during the health
history, consist of information that the client gives about
himself or herself. Objective data are obtained through
physical examination and vital signs measurements, what
the nurse observes, and laboratory study and diagnostic
test results. Allergies, the date of the client’s last
menstrual period, and the reported use of medication for
headaches are all subjective data.
Test-Taking Strategy: Use the process of elimination.
Eliminate the comparable or alike options that include data
that the nurse would obtain from the client during the
health history. Review the difference between subjective
and objective data if you had difficulty with this question.
Cognitive Ability: Understanding
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
Ques 1 / 1 pts tion 3
A nurse is reading the report from the registered nurse for an
initial home visit to a client with chronic obstructive pulmonary
disease. The client was recently discharged from the hospital.
Which type of database does the nurse read that contains this
information from the client?
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Episodic Follow-up Emergency
Correct! Complete
Rationale: A complete database includes a complete
health history and a full physical examination. It describes
the client’s current and past state of health and forms a
baseline against which all future changes can be
measured. The complete database is collected in a
primary care setting, such as a pediatric or family practice
clinic; an independent or group private practice; a college
health service; a women’s health care agency; a visiting
nurse agency; or a community health agency. An episodic
database is compiled for a limited or short-term problem
and is focused mainly on one problem or one body
system. A follow-up database is used to evaluate an
identified problem at regular and appropriate intervals. An
emergency database involves the rapid collection of the
data that are often compiled as lifesaving measures are
being performed.
Test-Taking Strategy: Use the process of elimination.
Noting the strategic words “initial home visit” in the
question will direct you to the correct option. Review the
different types of databases if you had difficulty with this
question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
Ques 1 / 1 pts tion 4
A 25-year-old client was seen in the clinic 2 weeks ago for
symptoms of a cold and is now complaining of chest congestion
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and cough. The nurse should assist with the data collection by
collecting which information?
Data related to follow-up care A complete (total health) database
Correct! Data related to the respiratory system
Data related to the treatment for the cold
Rationale: An episodic database is compiled for a limited
or short-term problem and is focused mainly on one
problem or body system. The history and examination will
be focused primarily on the respiratory system in this
client. A complete database includes a complete health
history and a full physical examination. It describes the
client's current and past state of health and forms a
baseline against which all future changes can be
measured. A follow-up database is used to evaluate an
identified problem at regular and appropriate intervals.
Test-Taking Strategy: Use the process of elimination.
Focusing on the data in the question and noting the words
“now complaining of chest congestion and cough” will
direct you to the correct option. Review the different types
of databases if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
Question 5 1 / 1 pts
A client is brought to the emergency department after a motor
vehicle accident. The client is alert and cooperative but has
sustained multiple fractures of the legs. How should the nurse
proceed with data collection?
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Collect health history information first, then perform the physical
examination.
Ask health history questions while performing the examination
and initiating emergency measures.
Correct!
Collect all information requested on the history form, including
social support, strengths, and coping patterns.
Perform emergency measures and not ask any health history
questions until the client’s fractures have been treated in the
operating room.
Rationale: If the client is alert and cooperative and if the
situation is not life-threatening, the nurse should attempt to
obtain as much subjective and objective data as possible
while caring for the client. Collecting health history
information and then performing the physical examination
does not address the priority, which is treating the client.
Collecting all data requested on the history does not
specifically address the client's immediate problems.
Performing emergency measures and not asking any
health history questions does not address data collection
before treatment.
Test-Taking Strategy: Use the process of elimination.
Focus on the data in the question and note the strategic
words “alert and cooperative.” Noting that the client has
not sustained life-threatening injuries will direct you to the
correct option. Review the different types of databases if
you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
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Question 6 1 / 1 pts
A client who was given a diagnosis of hypertension 3 months ago
is at the clinic for a checkup. Which type of database does the
nurse use in performing an assessment?
Emergency
Correct! Follow-up
Complete (total) Problem-centered
Rationale: A follow-up database is compiled to evaluate
the status of an identified problem at regular and
appropriate intervals. An emergency database calls for
rapid collection of the data, often at the same time
lifesaving measures are being performed. A complete
database includes a complete health history and a full
physical examination. It describes the client's current and
past state of health and forms a baseline against which all
future changes can be measured. An episodic database
(problem-centered) is compiled for a limited or short-term
problem. It is focused mainly on one problem or body
system.
Test-Taking Strategy: Focus on the data in the question.
Noting the strategic words “at the clinic for a checkup” in
the question will direct you to the correct option. Review
the different types of databases if you had difficulty with
this question.
Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process/Data Collection
Content Area: Health Assessment/Physical Exam
Question 7 1 / 1 pts
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A Mexican American client with epilepsy is being seen at the
clinic for an initial examination. The nurse understands which
primary purpose of including cultural information in the health
assessment?
Confirm the medical diagnosis. Make accurate nursing diagnoses. Identify any hereditary traits related to the epilepsy.
Correct! Determine what the client believes has caused the epilepsy. [Show Less]