A nurse is caring for a client who states, "I am under a great deal of stress at work, but I am able to forget my work and concentrate on my family when I get home at night." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Choice A reason : The term "alert" is an objective finding in the nursing assessment. It refers to the client's level of consciousness and responsiveness to stimuli, which can be directly observed and measured by the nurse during the evaluation. Being alert is a state that is evident through the client's behavior, responses, and interactions.

Choice B reason : "Pacing" is an objective finding. It is a visible behavior that can be observed and documented by the nurse without the need for interpretation or reliance on what the client says. Pacing can be quantified by the number of times the client walks back and forth in a given period.

Choice C reason : "Anxiety" is a subjective finding because it is based on the client's personal feelings and cannot be directly observed or measured by the nurse. It is reported by the client and requires the nurse to rely on the client's expression of their emotional state.

Choice D reason : "Restless" is an objective finding. Restlessness can be observed as physical movements, such as the inability to stay still, fidgeting, or frequent changes in position. These are behaviors that the nurse can see and document.

The correct answer is: B. Identity vs. Role Confusion.

Choice A reason:

Autonomy vs. Shame and Doubt occurs in early childhood (ages 1-3). During this stage, children develop a sense of personal control over physical skills and a sense of independence. The focus is on developing autonomy, not on the social dynamics typical of adolescence.

Choice B reason:

Identity vs. Role Confusion is the stage that occurs during adolescence (ages 12-18). In this stage, teenagers explore their independence and develop a sense of self. They may rebel against caregivers and spend more time with peers as they form their identity and navigate social roles. This stage is crucial for developing a personal identity and a sense of direction in life.

Choice C reason:

Integrity vs. Despair occurs in late adulthood (ages 65 and older). This stage involves reflecting on one's life and either coming to terms with it or feeling a sense of despair over missed opportunities. It is not relevant to the experiences of an adolescent.

Choice D reason:

Trust vs. Mistrust is the first stage of Erikson's theory, occurring in infancy (birth to 18 months). This stage focuses on developing trust when caregivers provide reliability, care, and affection. A lack of this leads to mistrust. It does not pertain to the adolescent's developmental challenges.