The nurse is performing a nutritional assessment. Which of the following would be considered objective data?
Dietary history from the patient
BMI (Body Mass Index)
Patient history of alcohol intake
Patient complaint of weight loss
The Correct Answer is B
A) Dietary history from the patient: This information is subjective as it relies on the patient’s personal account of their eating habits, which may be influenced by memory or perception. It does not provide measurable data.
B) BMI (Body Mass Index): This is an objective measure calculated from a person’s height and weight. It provides quantifiable data that can be used to assess nutritional status and potential health risks associated with body weight.
C) Patient history of alcohol intake: This information is subjective as it is based on the patient’s self-report. It does not provide direct evidence and may vary depending on how the patient perceives their alcohol consumption.
D) Patient complaint of weight loss: This is also subjective data, as it relies on the patient’s perception of their weight change. It does not provide concrete measurements and can be influenced by various factors such as mood or misunderstanding of the situation.
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Correct Answer is C
Explanation
A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.
B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."
C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.
D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.
Correct Answer is A
Explanation
A) Symmetry: During a breast inspection, the nurse should assess for symmetry between the two breasts. It is normal for there to be some slight differences, but significant asymmetry can indicate underlying issues that may need further evaluation.
B) Hard nodules: While the presence of hard nodules would be a significant finding, this would typically be assessed through palpation rather than inspection. The initial visual assessment focuses on appearance, shape, and symmetry.
C) Skin texture: Skin texture may be observed during inspection, but it is not a primary finding that stands out as a key assessment element. It can be noted as part of a comprehensive evaluation but is not the main focus.
D) Tenderness: Tenderness is a subjective assessment that is evaluated through palpation and client reporting, rather than through inspection. The nurse cannot document tenderness solely based on visual assessment.