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 B
Explanation
A) Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2: While this option describes the left extremity and includes some relevant details, it inaccurately uses "normal pitting edema" without specifying the degree of edema clearly. Additionally, it lists the posterior tibial pulse instead of the popliteal, which is more appropriate given the anatomical location.
B) Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2: This documentation accurately describes the left lower extremity, specifies the degree of edema as "+2," and correctly identifies the relevant pulses as femoral, popliteal, and dorsalis pedis. This terminology is clear and concise, providing a comprehensive assessment of the vascular status.
C) Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal: This option incorrectly reports the degree of edema as "+4," which indicates severe swelling, not matching the original assessment of "mild edema." It also incorrectly lists the posterior tibial pulse, which should be popliteal.
D) Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal: The term "normal cool temperature" is confusing and not standard terminology. Additionally, "slight swelling" lacks specificity regarding the degree of edema, which is important for a clinical assessment. Furthermore, it inaccurately refers to the posterior tibial pulse instead of the popliteal.
Correct Answer is C
Explanation
A) Third left ICS: The third left intercostal space (ICS) is typically associated with the auscultation of the pulmonic valve rather than the tricuspid valve. While it is in the vicinity of the heart, it is not the correct location for assessing the tricuspid area.
B) Second right ICS: The second right intercostal space is where the aortic valve is best heard. This location is important for assessing blood flow through the aorta, but it is not relevant for the tricuspid valve auscultation.
C) Fourth left ICS: The tricuspid valve is best auscultated at the fourth left intercostal space along the left sternal border. This area allows for optimal listening to the sounds produced by the tricuspid valve, providing important information about right heart function.
D) Second left ICS: The second left intercostal space is the auscultation point for the pulmonic valve, not the tricuspid valve. While this area is critical for assessing the heart, it does not correspond to the location for the tricuspid valve.