Which entry is subjective data in a nursing record?
Correct answer: B. Patient states, "My pain is 8 out of 10"
- A. Temperature is 38.4°C by oral thermometer
- B. Patient states, "My pain is 8 out of 10"
- C. Respiratory rate is 28 breaths per minute
- D. Skin is cool and clammy on examination
Explanation
Subjective data are symptoms or feelings reported by the patient, such as a pain score. Temperature, respiratory rate and skin findings are objective observations that the nurse can measure or assess.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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