A nurse is performing an assessment. which findings will the nurse report as subjective data?
Show NURSINGTB.COM Prime yourself for your Tests – Study Questions Chapter 16: Nursing Assessment Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? Completes a comprehensive database Identifies pertinent nursing diagnoses Intervenes based on priorities of patient care Determines whether outcomes have been achieved ANS: A The assessment phase of the nursing process involves data collection to complete a thorough patient database and is the first phase. Identifying nursing diagnoses occurs during the diagnosis phase or second phase. The nurse carries out interventions during the implementation phase (fourth phase), and determining whether outcomes have been achieved takes place during the evaluation phase (fifth phase) of the nursing process. 2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? Complete the questions in chronological order. Focus on the patient’s presenting situation. Make accurate interpretations of the data. Conduct an observational overview. ANS: B A problem-oriented approach focuses on the patient’s current problem or presenting situation rather than on an observational overview. The database is not always completed using a chronological approach if focusing on the current problem. Making interpretations of the data is not data collection. Data interpretation occurs while appropriate nursing diagnoses are assigned. The question is asking about data collection. NURSINGTB.COM FUNDAMENTALS OF NURSING 9TH EDITION POTTER TEST BANK 1. The use of critical thinking skills during the assessment phase of the nursing process ensures that the nurse ANS: A 2. A nurse using the problem-oriented approach to data collection will first ANS: C 3. After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistant. With this in mind, what clinical decision should the nurse make? ANS: C 4. Subjective data include ANS: A 5. A patient expresses fear of going home and being alone. Her vital signs are stable and her incision is nearly completely healed. The nurse can infer from the subjective data that ANS: C 6. Which of the following methods of data collection is utilized to establish a patient’s nursing database? ANS: C 7. To gather information about a patient’s home and work surroundings, the nurse will need to utilize which method of data collection? ANS: C 8. While
interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. This nurse should ANS: B 9.
After setting the agenda during a patient-centered interview, what will the nurse do? ANS: B 10. The nurse is
attempting to prompt the patient to elaborate on her complaints of daytime fatigue. Which question should the nurse ask? ANS: B 11. Components of a nursing health history include ANS: D 12. While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about
an inability to rest at night. The nurse disregards this complaint, thinking that no correlation has been noted between having a leg cast and developing restless sleep. A more theoretically sound approach would be to first ANS: D 13. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). The nurse is performing what type of assessment approach in this situation? ANS: D 14. A nurse comparing data validation and data interpretation correctly explains the difference with which statement? ANS: C 15. Which scenario best illustrates the use of data validation when making an independent nursing clinical decision? ANS: A 16. While completing an admission database, the nurse is interviewing a patient who states that he is allergic to latex. The most appropriate nursing action is to first ANS: B 17. A patient
verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s best action in response to her observation? ANS: D 18. The nurse is assessing a patient with a hearing deficit. Where is the best place to conduct this interview? ANS: A 19. A nursing student is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which of the following actions made by the nursing student requires the nursing professor to
intervene? ANS: B 1. Which of the following are examples of subjective data? (Select all that
apply.) ANS: A, C What is subjective data in nursing assessment?Subjective nursing data are collected from sources other than the nurse's observations. This type of data represents the patient's perceptions, feelings, or concerns as obtained through the nursing interview. The patient is considered the primary source of subjective data.
What are subjective assessment findings?Subjective data is anecdotal information that comes from opinions, perceptions or experiences. Examples of subjective data in health care include a patient's pain level and their descriptions of symptoms.
What is considered subjective assessment data?As the word “subjective” suggests, this type of data refers to information that is spontaneously shared with you by the client or is in response to questions that you ask the client. Subjective data can include information about both symptoms and signs.
When performing a patient assessment the nurse recognizes that subjective data includes?Objective data are limited to that which the nurse can perceive or measure with one of the nurse's senses: hearing, seeing, touching, or smelling. Subjective data is that which only the patient can perceive and tell the nurse about, such as pain, family history, or the patient's feelings.
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