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

Answer and Explanation

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 B

Explanation

Choice A reason : While nasopharyngeal suctioning may be necessary to clear secretions, it should be done with the client's consent and in a manner that maintains their dignity. It is not the primary action to support dignity.

Choice B reason : Giving the client privacy during care is a fundamental way to support their dignity. It respects their personal space and autonomy, even in a vulnerable state.

Choice C reason : Demonstrating empathy is crucial in end-of-life care, as it acknowledges the client's feelings and experiences. However, it is not an action but rather an approach or attitude.

Choice D reason : Providing care with an optimistic attitude can be supportive, but it must be balanced with realism, especially in end-of-life situations where the focus is on comfort and dignity.

Choice E reason : Telling the client that their condition will improve may not be appropriate in end-of-life care, as it may not be truthful and could undermine trust.

A. Have an eye exam every 2 years B. It is caused by an increase in intraocular pressure. C. Clouding of the lens is a manifestation of diabetic retinopathy. D. "Seeing spots is a manifestation of diabetic retinopathy."

Correct Answer is D

Explanation

Choice A reason : Have an eye exam every 2 years.For individuals with diabetes, it is recommended to have an eye exam annually, not every two years, due to the high risk of developing diabetic retinopathy and the need for early detection and treatment.

Choice B reason : It is caused by an increase in intraocular pressure.Diabetic retinopathy is not caused by an increase in intraocular pressure; that is more characteristic of glaucoma. Diabetic retinopathy is caused by damage to the blood vessels in the retina due to high blood sugar levels.

Choice C reason : Clouding of the lens is a manifestation of diabetic retinopathy.Clouding of the lens is a manifestation of cataracts, not diabetic retinopathy. Diabetic retinopathy involves changes to the blood vessels in the retina, not the lens of the eye.

Choice D reason : "Seeing spots is a manifestation of diabetic retinopathy.""Seeing spots," or floaters, can indeed be a manifestation of diabetic retinopathy. This occurs when blood vessels in the retina are damaged and leak blood or other fluids, causing these spots to appear in the vision.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at the end of life. Which of the following actions should the nurse take to support the client's dignity?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who has diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who has impaired speech. Which of the following actions should the nurse take?

A nurse is caring for a client who is at the end of life and is experiencing dyspnea. Which of the following actions should the nurse take?

A nurse is assisting with teaching a class about Piaget's stages of cognitive development. The nurse should reinforce that abstract thinking develops during which of the following stages?

A nurse is caring for a client who reports experiencing flashbacks of a traumatic event that occurred a year ago. The nurse should identify that the client is experiencing which of the following stress-related disorders?

A nurse is caring for a client who has a terminal diagnosis and states, "I am ready to update my will." The nurse should identify that the client is experiencing which of the following Kübler-Ross stages of grief?

A nurse is caring for a client who is at the end of life and is unresponsive. Which of the following actions should the nurse take?

A nurse is assisting with teaching a class about cultural bias in health care. The nurse should include that which of the following can occur as a result of cultural bias?

A nurse is assisting with teaching a class about vulnerable populations that are at risk for health disparities. The nurse should include that a client who lives in a crowded apartment building is at risk for which of the following conditions?