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
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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Related Questions
Correct Answer is D
Explanation
Not knowing what triggered the allergic reaction is a significant concern and may indicate a need for allergy testing and evaluation by an allergy specialist. Identifying the trigger allergen is crucial for implementing avoidance strategies, preventing future allergic reactions, and managing the client's overall health and well-being.
A. While the administration of epinephrine indicates the severity of the allergic reaction and the need for immediate treatment, it may not be the most important indication for referral to an allergy specialist on its own.
B. A biphasic reaction refers to the recurrence of symptoms after an initial resolution of an allergic reaction. Biphasic reactions can occur within hours or days after the initial reaction and can be severe or even life-threatening. This, however, does not necessitate need for a specialist.
C. While severe hypoglycemia can occur in some cases of anaphylaxis, it may not be the primary indication for referral to an allergy specialist.
Correct Answer is ["B","D"]
Explanation
B. Assessing the client's reliability as a historian involves gathering information about their medical history, symptoms, and health behaviors. While this is an important aspect of client assessment, it may not be immediately necessary right before performing the physical exam.
D. Constructing the client's family genogram is an important aspect of assessing their family history, which may be relevant to their current health condition. However, this task is not immediately necessary right before performing the physical exam and can be completed at a later time during the assessment process.
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