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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Correct Answer is D
Explanation
Choice A reason : Using high-pitched tones is not recommended when speaking to a client with hearing loss. High-pitched sounds can be harder to hear for many people with hearing loss, as these sounds are often the first to be affected by auditory impairment. It's better to use a lower, natural tone and speak clearly.
Choice B reason : Speaking to the client using a loud voice is not advisable. While it might seem helpful, shouting can actually distort speech sounds and make it more difficult for the client to understand. Instead, the nurse should speak in a normal, clear voice and ensure the client's hearing aids are functioning if they use them.
Choice C reason : Talking quickly can make it difficult for a client with hearing loss to understand what is being said. It is important to speak at a moderate pace, enunciating clearly and allowing the client time to process the information. Rapid speech can blend words together, making it challenging for the client to follow the conversation.
Choice D reason : Making eye contact with the client when speaking is an effective communication strategy. It helps to engage the client and allows them to use visual cues such as lip-reading and facial expressions to better understand the conversation. Additionally, it ensures that the nurse has the client's attention before speaking.
Correct Answer is D
Explanation
Choice A reason : Change in marital status.A change in marital status is considered a social stressor rather than a physiological one. It relates to the personal and emotional aspects of one's life, impacting mental and emotional well-being rather than directly causing a physiological response.
Choice B reason : Financial difficulties.Financial difficulties are categorized as social stressors. They can lead to significant stress but do not directly cause a physiological response. Instead, they can indirectly affect health over time through sustained stress.
Choice C reason : Academic pressure.Academic pressure is a psychological stressor. It involves cognitive and emotional challenges that can lead to stress but is not a direct physiological stressor.
Choice D reason : Burn injury.A burn injury is a physiological stressor. It causes an immediate physical response in the body, triggering pain receptors, inflammatory responses, and the need for physical healing processes.
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