An ER nurse is interviewing a client who complains of abdominal ...

[schs14]

An ER nurse is interviewing a client who complains of abdominal pain. Which of the following questions asked by the nurse has priority at this time?
 
  1. Can you describe your pain?
  2. Have you had this problem before?
  3. What have you done to ease the pain?
  4. When did your abdominal pain begin?

Question 2

After visiting with the client, the nurse documents the assessment data. Both objective and sub-jective information have been obtained during the assessment. Which of the following is classi-fied as subjective data?
 
  1. Client appears sleepy
  2. No physical distress noted
  3. Abdomen soft and non-tender
  4. States feels anxious and tense

[ong527]

Answer to Question 1

ANS: 4
If a client presents to the emergency department with pain, the nurse should first ask the client about the onset, severity, and duration of the pain. In an emergency situation, the client's current health problem becomes the priority assessment. Gathering data about the problem currently af-fecting the client has greater priority, but a description of the pain does not have priority over onset. Asking the client about medical history is appropriate but not at this time. The priority is to assess the symptoms the client is experiencing. Gathering data about the problem currently af-fecting the client has greater priority, but attempted self-treatment does not have priority over onset.

Answer to Question 2

ANS: 4
Subjective data are clients' perceptions about their health problems. Feeling anxious and tense is information that only the client can provide. Objective data are observations or measurements made by the data collector. In this example, the data collector is making the observation that the client appears sleepy. No physical distress noted is an example of objective data because it is an observation made by the data collector. Abdomen soft and non-tender is an example of objec-tive data because it is an observation made by the data collector, not a client's perception.

[schs14]

Gracias!

[Joy Chen]

TYSM