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","C"]

Explanation

This information is relevant to the client's condition and should be documented in the medical record. It provides important information about the client's physical status following the fall and may influence subsequent care decisions.

B. This information is typically documented in the incident report itself rather than the client's medical record. While it is important for the healthcare facility's records, it is not typically included in the client's medical record unless there are specific policies or procedures mandating such documentation.

C. This information is more relevant to administrative records and risk management procedures rather than the client's medical record.

D. This information is relevant to the client's care and should be documented in the medical record. It indicates that appropriate actions were taken following the incident.

A. Telephone the interpreter that is designated for the facility to interpret the information, B. Ask the client's partner to interpret the information. C. Call a nursing colleague who speaks the same language as the client to interpret the information. D. Use an electronic translating service from the internet to interpret the information.

Correct Answer is A

Explanation

Telephone the interpreter that is designated for the facility to interpret the information is a preferred option as it ensures accuracy and confidentiality in communication.
B. While involving the client's partner may seem convenient, it is not the preferred option for several reasons.
C. While having a colleague who speaks the same language as the client can be helpful, it is not always a reliable option.
D. While electronic translating services can provide a quick solution, they may not always accurately translate medical terminology or convey the nuances of communication.

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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

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Correct Answer is ["B","C"]

Explanation

A nurse is admitting a client who speaks a different language than the nurse. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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