QLexNursing

🔹 Subjective data refers to information that the client reports about their own experiences, feelings, or perceptions, which cannot be directly measured.

🔹 The client’s statement, "I have difficulty concentrating during class due to auditory hallucinations," reflects their personal perception and internal experience.

🔹 Even though the nurse may observe behavior later (like whispering), the statement itself remains the client’s self-report, which is classic subjective data.

🔹 Nurses document subjective data usually in quotation marks to capture exact wording, such as “client states…” or “client reports…”.

🔹 Therefore, the best way to categorize this client’s statement in documentation is as subjective data.

Objective data

🔹 Objective data are findings that can be observed, measured, or verified by the nurse, such as vital signs, behavior, or physical findings.

🔹 An example in this scenario would be the nurse hearing the client whispering when no one else is around, which could be documented as an observed behavior.

🔹 The client’s internal experience of difficulty concentrating and hearing voices cannot be confirmed directly by measurement, so it is not objective.

🔹 Mixing subjective statements into objective sections can blur the distinction between what the client reports and what the nurse observes.

🔹 Thus, the client’s verbal report should not be labeled as objective data.

Assessment finding

🔹 An assessment finding often refers to a synthesis or interpretation of collected data, such as concluding that the client is responding to internal stimuli.

🔹 While the client’s statement contributes to assessment, the question specifically asks how to document the statement itself, not the interpretation.

🔹 Labeling it simply as an “assessment finding” is too vague and does not clarify that it was self-reported.

🔹 Good documentation clearly distinguishes subjective (what the client says) from objective (what the nurse observes).

🔹 Therefore, “assessment finding” is not the best term for categorizing the exact client quote.

Secondary data

🔹 Secondary data are obtained from sources other than the client, such as family members, medical records, or previous providers.

🔹 In this scenario, the information comes directly from the client, making it primary, not secondary, data.

🔹 Using the term secondary data would suggest that someone else reported the client’s hallucinations or concentration problems.

🔹 Accurate classification is important to reflect the origin of the information, especially in mental health documentation.

🔹 Thus, the client’s statement is not secondary data and should be documented as subjective data instead.