A nurse is assessing a client who reports feeling stress and anxiety. The client appears restless and is pacing in the room. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?

Alert

Restless

Anxiety

Pacing

Answer and Explanation

The Correct Answer is C

Anxiety is a subjective emotional state characterized by feelings of worry, nervousness, or unease. If the client reports feeling anxious, this would be considered subjective because it is based on their own perception of their emotional state.

A. Alert refers to the client's level of consciousness and awareness of their surroundings.

B. Restlessness refers to a feeling of agitation or inability to stay still.

D. Pacing is an observable behavior where the client is walking back and forth in the room.

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Correct Answer is D

Explanation

Given the traumatic nature of sexual assault and the potential for re-traumatization, the assessment of the genitalia and rectum should be conducted last. This allows the nurse to build rapport with the client, establish trust, and address any immediate concerns or needs before proceeding with a potentially distressing examination.

A. "Would you tell me about all of your medical issues?" B. "What brought you to the hospital?" C. "Would it help to discuss your feelings about this hospitalization?" D. "Do you want to talk about your health concerns?"

Correct Answer is B

Explanation

This question is more focused and directly addresses the reason for the client's current admission. It prompts the client to discuss their chief complaint or presenting symptoms, which is essential information for the nurse to gather during the health history interview.
A. This question is too broad and may overwhelm the client, especially during the initial stages of the health history interview.
C. While discussing the client's feelings about hospitalization is important for providing emotional support and understanding their perspective, this question may not directly promote the discussion of health history data.
D. This question invites the client to share their perspective and provides an opportunity for them to express any immediate health issues or worries they may have. However, it is too broad.

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A nurse is assessing a client who reports feeling stress and anxiety. The client appears restless and is pacing in the room. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

Correct Answer is D

Explanation

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

Correct Answer is B

Explanation

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A nurse in the emergency department is caring for a client who was sexually assaulted. Which of the following resources will provide the most effective support immediately following the incident?

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