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

Answer and Explanation

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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Correct Answer is ["B","D","E"]

Explanation

Choice A reason : Using a cane to ambulate is generally a measure to improve stability and reduce the risk of falling for individuals who may have balance or mobility issues. It is not inherently a risk factor for falls; rather, it is a compensatory strategy to mitigate the risk of falls1.
Choice B reason : Macular degeneration can significantly impact visual acuity and contrast sensitivity, leading to difficulties in navigation and increasing the risk of tripping or misjudging distances. Poor vision is a well-documented risk factor for falls, especially in unfamiliar or complex environments.
Choice C reason : A grab bar in the bathroom is a safety device installed to provide stability and support for individuals while they are using the bathroom facilities. It is a preventive measure against falls and does not increase the risk of falling.
Choice D reason : An electrical cord on the floor over a walkway is a tripping hazard. It is a common home hazard that can cause falls, especially in the elderly or those with mobility and visual impairments78.
Choice E reason : Unsecured throw rugs over tile floors are a recognized fall hazard. They can easily slip underfoot or cause tripping if the edges are not secured, which is particularly dangerous in areas like the kitchen where spills can make the floor even more slippery.

A. Allow extra time to communicate with the client. B. Ask open-ended questions. C. Finish sentences for the client. D. Avoid using visual aids for communication.

Correct Answer is A

Explanation

Choice A reason : Allow extra time to communicate with the client.Allowing extra time to communicate is essential when caring for clients with impaired speech. This approach respects the client's pace and supports their efforts to express themselves, which can be a time-consuming process. It also helps to reduce frustration and anxiety that the client may feel if rushed⁵.

Choice B reason : Ask open-ended questions.Asking open-ended questions to a client with impaired speech can be challenging for them to answer and may lead to frustration. Instead, it's recommended to ask yes/no questions or provide choices to facilitate easier communication⁵.

Choice C reason : Finish sentences for the client.Finishing sentences for a client with impaired speech is generally discouraged as it can lead to miscommunication and may make the client feel disempowered. It's important to allow the client to express themselves in their own words and time⁵.

Choice D reason : Avoid using visual aids for communication.Using visual aids can be very helpful for clients with impaired speech. Visual aids such as pictures, gestures, or writing can support understanding and expression, making communication more effective⁵.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Exhibits A nurse in a provider’s office is assisting with the review of fall risk data collected on a client. Which of the following findings places the client at risk for a fall? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

A nurse is caring for a client who has impaired speech. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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