Online Companion: Fundamentals of Nursing Standards and Practice 2E

Frequently Asked Questions

How does the nurse decide which data to collect from a patient?

The ANA provides standards for the collection of client data that state that the data must relevant to client needs, collected from a variety of sources, collected using appropriate techniques, collected in a systematic manner and documented in a usable format. These guidelines assist the nurse to determine which data are needed in a situation and guide the methods used to collect and document the data.

What does the nurse do when a client refuses to answer a question during the health history interview?

From the beginning of the interview, the nurse is sensitive to the client's responses and level of comfort during the interview. The nurse observes for nonverbal messages that the client is tiring or is having difficulty remembering data or is reluctant to answer questions. The nurse can share observations and ask the client to validate these. The nurse uses the interview to develop rapport with the patient. Sensitive or very personal questions are asked after this rapport has developed. Throughout the assessment process the nurse reassures the client about the confidential nature of the data collection and informs the client about the importance of the data to the plan of care.

What happens when inconsistencies are found in data?

The nurse evaluates the reliability of the data sources being used. in data collection. If inconsistencies in client's health history are noted, the nurse may ask the client or the family to clarify the discrepancy. If physical exam data or laboratory data are inconsistent, the nurse may recheck findings by repeating a part of the exam or having the lab specimen rechecked to establish accuracy. Sometimes the inconsistency cannot be resolved and the data is documented noting the inconsistency that exists

How is the subjective data different from the objective data?

The subjective data, also called symptoms, are the data that the client reports. They include feelings, perceptions and concerns. The client tells the nurse "I have pain in my leg." This is subjective data. The nurse observes that the patient is avoiding walking on the leg and that the lower leg is swollen and red. These are objective data, also referred to as signs. The nurse can observe and measure signs. Each type of data is important to a comprehensive assessment.