A nurse is collecting data on a client who reports feeling stress and anxiety. The client appears restless and is pacing. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?
Alert
Pacing
Anxiety
Restless
Restless
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : Increasing intake of saturated fats is not recommended for reducing stress. Saturated fats can contribute to the development of heart disease by raising cholesterol levels and should be limited in a healthy diet.
Choice B reason : Limiting alcohol intake is generally a good practice, but specifying "3 drinks per day" is not accurate. The Dietary Guidelines for Americans recommend up to one drink per day for women and up to two drinks per day for men.
Choice C reason : Choosing complex carbohydrates each day is beneficial for managing stress. Complex carbohydrates can increase the amount of serotonin in the brain, which has a calming effect. Foods rich in complex carbohydrates include whole grains, fruits, vegetables, and legumes⁷.
Choice D reason : Consuming less than 2000 mg of sodium per day is part of a healthy diet, but it is not specifically related to stress reduction. The American Heart Association recommends no more than 2300 mg a day and moving toward an ideal limit of no more than 1500 mg per day for most adults.
Correct Answer is B
Explanation
Choice A reason : While assisting the client in identifying coping strategies that have worked in the past is important, it is not the first step in assessing self-concept. Coping strategies are part of a broader plan to manage self-concept issues once they have been identified.
Choice B reason : Identifying health alterations that are related to self-concept is the first step in the assessment process. Understanding how health changes affect the client's perception of themselves can provide a foundation for further exploration and intervention planning.
Choice C reason : Collaborating with the client to establish short and long-term goals is an important part of the care plan but should come after a thorough assessment of the client's self-concept and related health alterations.
Choice D reason : Determining whether the desired outcome has been achieved is part of the evaluation phase of the nursing process and should occur after interventions have been implemented, not during the initial assessment of self-concept.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.