A nurse is assessing a patient who reports feeling stress and anxiety.

The patient appears restless and is pacing in the room.

The patient is alert and oriented to person, place, and time.

Which of the following findings is subjective?

Choice A rationale
Initiating life-saving measures such as a rapid response call would not be appropriate in this context. The patient is in a hospice setting, which focuses on providing comfort and quality of life for patients who are nearing the end of life, rather than aggressive life-saving interventions.
Choice B rationale
Calling the provider because these signs and symptoms are abnormal would not be the correct response. In a hospice setting, these symptoms are expected and are indicative of the natural dying process.
Choice C rationale
The statement that rapid respirations that are unusually deep and regular are curative for the patient is incorrect. Cheyne-Stokes respirations, characterized by a pattern of increasing and then decreasing depth of breath followed by a period of apnea, are often seen in patients nearing the end of life. They are not curative but are a sign of the body’s decreasing metabolic demands and changing physiology as death approaches.
Choice D rationale
The nurse understanding that these are impending signs of death and are normal is the correct response. The symptoms described, including loss of appetite, swelling of the limbs, increased sleep, Cheyne-Stokes respirations, and hallucinations, are all common in the final stages of life.
Recognizing these signs can help the nurse provide appropriate care and support to the patient and their family during this time.

Choice A rationale
Socioeconomic stressors are related to a person’s social and economic status. Homelessness is a clear example of a socioeconomic stressor, as it is often caused by factors such as unemployment, poverty, and lack of affordable housing.
Choice B rationale
Adventitious stressors are unexpected and often traumatic events that occur outside of the normal course of life. These could include natural disasters, accidents, or violent crimes. While homelessness can be traumatic, it is not considered an adventitious stressor because it is related to the individual’s social and economic circumstances.
Choice C rationale
Developmental stressors are those that occur as a result of going through the normal stages of life, such as starting school, getting a job, getting married, having children, and retiring. Homelessness is not a developmental stressor because it is not a normal or expected part of life.
Choice D rationale
Cultural stressors are related to a person’s cultural background and experiences. While culture can influence a person’s socioeconomic status, homelessness itself is not a cultural stressor.