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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Wash the client’s body. This is a standard part of postmortem care to ensure the body is clean and presentable for the family and any further procedures.
Choice A reason:
Remove the client’s dentures. This statement is incorrect because dentures should be left in place to maintain the shape of the face and ensure a natural appearance for viewing by the family.
Choice B reason:
Increase the lights in the client’s room. This statement is incorrect because dim lighting is often preferred to create a calm and respectful environment for the family.
Choice C reason:
Place the head of the client’s bed flat. This statement is incorrect because the head should be elevated to prevent discoloration and pooling of blood.
Choice D reason:
Wash the client’s body. This is correct as it is a standard part of postmortem care to ensure the body is clean and presentable for the family and any further procedures.
Correct Answer is A
Explanation
Choice A reason : Trust vs. Mistrust.The stage of Trust vs. Mistrust is the first stage of Erikson's theory of psychosocial development, occurring from birth to approximately 18 months of age. In this stage, the infant is uncertain about the world and looks towards their primary caregiver for stability and consistency of care. If the caregiver is reliable, consistent, and nurturing, the child will develop a sense of trust, believing that the world is safe and that people are dependable and affectionate. This sense of trust allows the child to feel secure even when threatened and extends into their other relationships, maintaining their sense of security amidst potential threats.
Choice B reason : Autonomy vs. Shame and Doubt.The stage of Autonomy vs. Shame and Doubt is the second stage of Erikson's theory, spanning the toddler years from 18 months to three years. In this stage, toddlers begin to assert their independence by making choices and taking control over their actions. Success in this stage leads to feelings of autonomy, while failure results in feelings of shame and doubt. However, this stage is not applicable to the scenario described, as it involves an infant, not a toddler.
Choice C reason : Identity vs. Role Confusion.Identity vs. Role Confusion is the fifth stage, occurring during the teen years from 12 to 18. This stage is characterized by the exploration of personal identity and the development of a sense of self. The scenario provided does not pertain to an adolescent, so this stage is not relevant to the infant's experience.
Choice D reason : Integrity vs. Despair.The stage of Integrity vs. Despair is the eighth and final stage of Erikson's theory, occurring in older adulthood from 65 to death. This stage involves reflecting on one's life and either concluding it with a sense of integrity and fulfillment or with a sense of despair over a life misspent. This stage is not applicable to the infant described in the scenario.
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