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 B

Explanation

A. This is not be the most appropriate question to start with as it does not directly address the client's health concerns or reasons for seeking care.
B. This question It allows the client to identify their primary reason for seeking care and provides the nurse with essential information to guide the health history assessment. Starting with the client's major health concern helps to prioritize the assessment and address the client's immediate needs.
C. This question is broad and open-ended, which may lead to a vague or general response. Starting with a more focused question about the client's specific health concerns can provide more relevant information.
D. This is not appropriate for initiating the health history assessment. It may come across as confrontational or directive, which is not conducive to establishing rapport or gathering information about the client's health concerns.

A. Speak to the client in the third person. B. Make eye contact with the client when speaking C. Have the interpreter sit in front of the client. D. Use long sentences when speaking to the client.

Correct Answer is C

Explanation

A. The nurse should speak directly to the client in the first person, even when using an interpreter. Speaking in the third person can create confusion and distance in communication.

B. This action demonstrates respect and engagement with the client, even though the nurse is using an interpreter. Eye contact can help to build rapport and ensure that the client feels heard and understood.
C. The interpreter should ideally sit beside or slightly behind the nurse, allowing the nurse and client to see each other while the interpreter translates. This setup fosters a more personal interaction between the nurse and the client.
D. Using long sentences can make it difficult for the interpreter to accurately translate the message.

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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

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Correct Answer is C

Explanation

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