NR302 SUBJECTIVE/OBJECTIVE DATA
SELECT OBJECTIVE DATA: Client denies trouble breathing, states cough is persistent, and sputum production is decreasing. (Lung sounds are clear to auscultation) except (crackles in left lower lobe). (Oxygen saturation 96%) on room air. (BP 148/92), (T 100.6 °F (38.1 °C)) tympanic, (HR 114 bpm), (RR 24 per minute.)
- Lung sounds are clear to auscultation - Crackles in left lower lobe. - Oxygen saturation 96% - BP 148/92, T 100.6 °F (38.1 °C) - HR 114 bpm - RR 24 per minute
(Second-hand / Subjective / Objective) information is being recorded when the nurse documents a person's temperature is 102.1 °F (38.9 °C) and the heart rate is 126 beats per minute. Including that the person said they have felt sick for the last two days is an example of documenting (subjective / first-hand / objective / data)
- OBJECTIVE - SUBJECTIVE
SELECT SUBJECTIVE: The client presents with (sudden onset of blurred vision), (diplopia double vision) (bilateral arm weakness) with L > R, and left eye ptosis (droop). Lumbar puncture revealed increased protein in the cerebrospinal fluid (CSF). Social History: (Denies alcohol and tobacco use); retired teacher; (lives with spouse and two cats.) Allergies: (Acnotex and Bactrim DS)
- Sudden onset of blurred vision - Diplopia (double vision) - Bilateral arm weakness with L > R - Denies alcohol and tobacco use - Lives with spouse and two cats - Acnotex and Bactrim DS
SELECT SUBJECTIVE DATA: "I (fell down the stairs last evening) and (twisted my ankle.) I (put ice on it) right away and (kept it elevated,) but now (I can't put any weight on it.) I (took some ibuprofen) for the pain, but it is (still pretty bad.) I (don't think it is broken.")
- fell down the stairs last evening - twisted my ankle - put ice on it - kept it elevated - I can't put any weight on it - took some ibuprofen - still pretty bad
Which excerpt from the admission assessment should the nurse interpret as objective data? Client's clothes are wrinkled and dirty. Source of information: 17-year-old client and their mother Client admits to having suicidal thoughts that are increasing in frequency over the last few weeks. Mother frequently interrupts the client to contradict what they are saying. Chief complaint: "I need my depression medications changed."
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Which questions are asked by the nurse to obtain subjective data? 1. "Can you tell me about the last time your blood sugar got this high?" 2. "Does it hurt when I press here?" 3. "Is now a good time for me to check your blood pressure?" 4. "May I lift your shirt to listen to your lungs?" 5. "On a scale of 1-10, how badly does your knee hurt?"
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WHICH IS SUBJECTIVE: 1. List of foods eaten in the past 3 days 2. Blood sugar levels from the laboratory 3. Past medical history 4. Sensations 5. Feelings
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Objective data / Subjective data 1. What the nurse learns using the assessment techniques of inspection, palpation, percussion, and auscultation: 2. What the person shares about themselves:
1. O 2. S
- SUBJECTIVE DATA - OBJECTIVE DATA 1. WHAT EXAMINER LEARNS USING THE ASSESSMENT TECHNIQUES OF INSPECTION, PALPATION, PERCUSSION, AUSCULTATION - CAN BE MEASURED BY EXAMINER - FROM PHYSCIAL EXAM, LAB TEST, IMAGING 2. WHAT PERSON SHARES. WHAT SOMEONE CLOSE TO PT SHARES - CANT BE MEASURED BY EXAMINER - CHIEF COMPLAINT =, HISTORY OF ILLNESS, PMH, FAMILY HISTORY, PERSONAL/SOCIAL HISTORY
1. ONJECTIVE 2. SUBJECTIVE
SUBJECTIVE / OBJECTIVE 1. Listening 2. Touching 3. Looking 4. Smelling
1. S/O 2. O 3. O 4. O
Subjective Data Objective Data 1. Mrs. Johnson replies, "Not well at all. I feel like I only slept an hour all night." 2. Mrs. Johnson says she is cold. 3. Mrs. Johnson is shivering slightly. 4. Mrs. Johnson is guarding her abdomen. 5. Mrs. Johnson feels warm to the touch. 6. T = 101.4 °F (38.6 °C)
1. Subjective Data 2. Subjective Data 3. Objective Data 4. Objective Data 5. Objective Data 6. Objective Data
A client tells the nurse that they are very nervous, nauseated, and "feel hot." What type of data is this? 1. Introspective 2. Objective 3. Subjective 4. Reflective
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Which data is an example of objective information obtained during the health assessment of the client who fell down the steps and hurt their ankle? 1. Last menstrual period 1 month ago 2. The client's history of allergies 3. Swelling and bruising of the left ankle 4. The client's use of medications at home
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Which is an example of objective data? 1. The client saying that their left knee has been swollen and hot for the past 3 days 2. Client's partner sharing that they cannot touch the knee without the person moaning 3. Reported left knee pain 4. Hearing a popping sound when the left knee is extended
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Which of the following is subjective data? 1. Information provided by the client's medical record 2. Client heart rate of 86 bpm 3. Condition of the client's wound 4. Client reports of pain
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After completing an initial assessment of a client, the nurse has charted that their respirations are eupneic and their pulse is 58 beats per minute. This type of data is (factual / objective / speculative / subjective)
OBJECTIVE
SUBJECTIVE / OBJECTIVE: - WHAT EXAMINER OBSERVES, ORGANIZED ASSESMENT USING INSPECTION, PALPATION AND AUSCULTATION - ASESSED AND DOCUMENTED BY COMPARING RESULTS TO NORMAL RANGE - EX: BREATH SOUND, STRENGTH OF PULSE, APPEARENCE, VITAL SIGNS, DESCRIPTION OF SURGICAL - RECORDED USING COMBINATION OD CHECKLISTS AND NOTES. REFERRED TO AS CHARTING - NOT INCLUDE STATEMENT MADE BY OTHERS, CLIENT, FAMILY, NON HC PROFESSIONALS - DATA BY HC TEAM MEMBERS IS VALID
OBJECTIVE
SUBJECTIVE / OBJECTIVE: - WHAT PERSON SHARES ABOUT THEMSELVES / CLOSE TO THEM SHARES - COLLECT BY ASKING QUESTIONS, LISTENING AND CLARIFYING INFORMATION PROVIDED BY INDIVIDUAL OR THEIR REPRESENTATIVE - EX: REASON FOR CARE, RECALLED DIETARY INTAKE, DESCRIPTION OF PAIN, SUICIDE THOUGHTS, PMH SURGICAL HISTORY - CAN'T BE VERIFIED, MUST BE IN RECORD - DOES NOT INCLUDE JUDGEMENTS/CONCLUSIONS
SUBJECTIVE
These are vastly different but equally important for accurately identifying the needs of those seeking healthcare.
SUBJECTIVE/OBJECTIVE DATA
SELECT SUBJECTIVE: Upon assessment of vital signs, the client's (blood pressure was 190/92.) They were questioned about their medication adherence, and slowly during the course of the client interview, it was shared that (they had not refilled or taken their hypertension medications in over one year.) Client education and support for the current situation as well as a lengthy discussion about the consequences of non-adherence to medications was completed.
They had not refilled or taken their hypertension medications in over one year
