NUR 3481 David Carter Part 2 Documentation Assignments
Actual Exam 2026/2027 – Complete Assessment with
Detailed Rationales | 100% Verified | Pass Guaranteed – A+
Graded
Section A: Subjective Data Collection – History & Patient Interview
(Questions 1–5)
Q1: David Carter, a 38-year-old admitted with sickle cell crisis, states, "The pain in my
lower back and hips is aching and throbbing, and it's about an 8 out of 10." Which item
from the admission interview is classified as subjective data?
A. Scleral icterus noted in both eyes
B. Pain rated as 8/10, described as aching and throbbing [CORRECT]
C. Oral temperature of 37.2°C
D. Dorsalis pedis pulses palpable 2+ bilaterally
Correct Answer: B
Rationale: Subjective data are symptoms perceivable and reported only by the patient,
such as pain quality and intensity. Scleral icterus, temperature, and pulse quality are
objective findings observed or measured by the nurse.
Q2: During the interview David states, "The aching and throbbing pain is in my lower
back, hips, and left knee. It started two days ago, it's constant, it's an 8 out of 10, and
nothing makes it better." Using OLDCARTS, which follow-up question best completes the
pain assessment?
A. "Can you describe what the pain feels like?"
B. "How bad is the pain on a scale of 0 to 10?"
C. "Does the pain move or radiate to any other part of your body?" [CORRECT]
D. "When did the pain first begin?"
Correct Answer: C
Rationale: Radiation is the missing OLDCARTS element; quality, severity, onset, duration,
location, and palliation were already provided. Identifying radiation establishes the full
pain distribution and guides the focused assessment.
, Q3: While reviewing the medication history, David tells the nurse, "I ran out of my folic
acid last month and haven't taken it since." How should the nurse document this
information?
A. Objective data: "Patient nonadherent to prescribed medications."
B. Subjective data: "Patient states he has not taken folic acid for the past month."
[CORRECT]
C. Objective data in the flowsheet: "Medication compliance poor."
D. Inference: "Patient is irresponsible with home medications."
Correct Answer: B
Rationale: The statement is patient-reported information (subjective data) and must be
quoted or paraphrased without judgment. Labeling him "nonadherent" or "irresponsible"
is an unsupported inference, and patient statements cannot be charted as objective
data.
Q4: Which interview question best helps the nurse identify factors that may have
precipitated David's current sickle cell crisis?
A. "Do you have a family history of sickle cell disease?"
B. "When was your last complete physical examination?"
C. "Have you received the pneumococcal vaccine?"
D. "Have you had a recent infection, exposure to cold, or periods without adequate
fluids?" [CORRECT]
Correct Answer: D
Rationale: Infection, cold exposure, and dehydration are classic sickle cell crisis triggers,
so this question targets precipitating factors. Family history, physical examination
dates, and vaccination status are background data that do not identify the current
precipitant.
Q5: After the interview, the nurse initially documents, "Patient is in a lot of pain and
seems anxious." Which revision best separates subjective from objective data for
accurate documentation?
A. "Patient states pain is 8/10 in lower back and hips; lying still, guarding left knee, rapid
speech noted." [CORRECT]
B. "Patient appears very uncomfortable; pain level high; anxious behavior obvious."
C. "Pain seems severe based on the patient's vital signs and facial expressions."
D. "Patient reports severe pain; probable anxiety related to hospitalization."
Correct Answer: A
Rationale: Option A quotes the patient's report (subjective) alongside observable
behaviors (objective) without generalizations. Options B–D use vague terms ("seems,"
"appears") and mix interpretations or conclusions with the actual data.
Actual Exam 2026/2027 – Complete Assessment with
Detailed Rationales | 100% Verified | Pass Guaranteed – A+
Graded
Section A: Subjective Data Collection – History & Patient Interview
(Questions 1–5)
Q1: David Carter, a 38-year-old admitted with sickle cell crisis, states, "The pain in my
lower back and hips is aching and throbbing, and it's about an 8 out of 10." Which item
from the admission interview is classified as subjective data?
A. Scleral icterus noted in both eyes
B. Pain rated as 8/10, described as aching and throbbing [CORRECT]
C. Oral temperature of 37.2°C
D. Dorsalis pedis pulses palpable 2+ bilaterally
Correct Answer: B
Rationale: Subjective data are symptoms perceivable and reported only by the patient,
such as pain quality and intensity. Scleral icterus, temperature, and pulse quality are
objective findings observed or measured by the nurse.
Q2: During the interview David states, "The aching and throbbing pain is in my lower
back, hips, and left knee. It started two days ago, it's constant, it's an 8 out of 10, and
nothing makes it better." Using OLDCARTS, which follow-up question best completes the
pain assessment?
A. "Can you describe what the pain feels like?"
B. "How bad is the pain on a scale of 0 to 10?"
C. "Does the pain move or radiate to any other part of your body?" [CORRECT]
D. "When did the pain first begin?"
Correct Answer: C
Rationale: Radiation is the missing OLDCARTS element; quality, severity, onset, duration,
location, and palliation were already provided. Identifying radiation establishes the full
pain distribution and guides the focused assessment.
, Q3: While reviewing the medication history, David tells the nurse, "I ran out of my folic
acid last month and haven't taken it since." How should the nurse document this
information?
A. Objective data: "Patient nonadherent to prescribed medications."
B. Subjective data: "Patient states he has not taken folic acid for the past month."
[CORRECT]
C. Objective data in the flowsheet: "Medication compliance poor."
D. Inference: "Patient is irresponsible with home medications."
Correct Answer: B
Rationale: The statement is patient-reported information (subjective data) and must be
quoted or paraphrased without judgment. Labeling him "nonadherent" or "irresponsible"
is an unsupported inference, and patient statements cannot be charted as objective
data.
Q4: Which interview question best helps the nurse identify factors that may have
precipitated David's current sickle cell crisis?
A. "Do you have a family history of sickle cell disease?"
B. "When was your last complete physical examination?"
C. "Have you received the pneumococcal vaccine?"
D. "Have you had a recent infection, exposure to cold, or periods without adequate
fluids?" [CORRECT]
Correct Answer: D
Rationale: Infection, cold exposure, and dehydration are classic sickle cell crisis triggers,
so this question targets precipitating factors. Family history, physical examination
dates, and vaccination status are background data that do not identify the current
precipitant.
Q5: After the interview, the nurse initially documents, "Patient is in a lot of pain and
seems anxious." Which revision best separates subjective from objective data for
accurate documentation?
A. "Patient states pain is 8/10 in lower back and hips; lying still, guarding left knee, rapid
speech noted." [CORRECT]
B. "Patient appears very uncomfortable; pain level high; anxious behavior obvious."
C. "Pain seems severe based on the patient's vital signs and facial expressions."
D. "Patient reports severe pain; probable anxiety related to hospitalization."
Correct Answer: A
Rationale: Option A quotes the patient's report (subjective) alongside observable
behaviors (objective) without generalizations. Options B–D use vague terms ("seems,"
"appears") and mix interpretations or conclusions with the actual data.
