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 A
Explanation
Choice A reason : Rationalization is a defense mechanism where an individual justifies behaviors or feelings with plausible but inaccurate explanations to avoid confronting the true underlying motives or facts. In this scenario, the client is rationalizing their failure to take medication by blaming their partner's forgetfulness, rather than accepting personal responsibility for their health management.
Choice B reason : Projection involves attributing one's own unacceptable thoughts, feelings, or motives to another person. If the client had accused their partner of being irresponsible with medication as a reflection of their own behavior, it would be an example of projection. However, in this case, the client is not projecting their own forgetfulness onto their partner but rather shifting the blame.
Choice C reason : Repression is an unconscious mechanism employed by the ego to keep disturbing or threatening thoughts from becoming conscious. It involves pushing uncomfortable thoughts or memories into the unconscious mind. The client's statement does not suggest they are unconsciously forgetting to take their medication; instead, they are consciously aware of their action and providing a justification for it.
Choice D reason : Regression is a return to earlier stages of development and abandoned forms of gratification belonging to them, prompted by dangers or conflicts arising at one of the later stages. A client demonstrating regression might exhibit childlike behaviors when faced with stress. The client's statement does not indicate a regression to more infantile behaviors or coping mechanisms.
Correct Answer is A
Explanation
Choice A reason : Trust vs. Mistrust.The stage of Trust vs. Mistrust is the first stage of Erikson's theory of psychosocial development, occurring from birth to approximately 18 months of age. In this stage, the infant is uncertain about the world and looks towards their primary caregiver for stability and consistency of care. If the caregiver is reliable, consistent, and nurturing, the child will develop a sense of trust, believing that the world is safe and that people are dependable and affectionate. This sense of trust allows the child to feel secure even when threatened and extends into their other relationships, maintaining their sense of security amidst potential threats.
Choice B reason : Autonomy vs. Shame and Doubt.The stage of Autonomy vs. Shame and Doubt is the second stage of Erikson's theory, spanning the toddler years from 18 months to three years. In this stage, toddlers begin to assert their independence by making choices and taking control over their actions. Success in this stage leads to feelings of autonomy, while failure results in feelings of shame and doubt. However, this stage is not applicable to the scenario described, as it involves an infant, not a toddler.
Choice C reason : Identity vs. Role Confusion.Identity vs. Role Confusion is the fifth stage, occurring during the teen years from 12 to 18. This stage is characterized by the exploration of personal identity and the development of a sense of self. The scenario provided does not pertain to an adolescent, so this stage is not relevant to the infant's experience.
Choice D reason : Integrity vs. Despair.The stage of Integrity vs. Despair is the eighth and final stage of Erikson's theory, occurring in older adulthood from 65 to death. This stage involves reflecting on one's life and either concluding it with a sense of integrity and fulfillment or with a sense of despair over a life misspent. This stage is not applicable to the infant described in the scenario.
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