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 : Decreased blood pressure is not a typical response to the fight-or-flight reaction. During this response, blood pressure usually increases due to the release of stress hormones like adrenaline, which cause the heart to beat faster and harder.

Choice B reason : Dilated pupils are a common manifestation of the fight-or-flight response. This physiological change allows more light into the eyes, which can improve vision and help an individual to better assess the situation and respond to potential threats.

Choice C reason : Bronchial airway constriction is not associated with the fight-or-flight response. In fact, the bronchial airways typically dilate to increase airflow and oxygen intake to prepare the body for action.

Choice D reason : Hypoglycemia, or low blood sugar, is not a direct result of the fight-or-flight response. The body actually mobilizes glucose stores, leading to elevated blood sugar levels, to provide energy for muscles during a stress response.

A. Inability to form healthy relationships B. Feelings of shame C. Bedwetting D. Overeating

Correct Answer is D

Explanation

Choice A reason : Inability to form healthy relationships is not typically associated with fixation at the oral stage of development. Freud's theory suggests that this issue is more related to the Oedipal conflict during the phallic stage, where the individual's interactions with parental figures shape their future relationships.

Choice B reason : Feelings of shame are generally associated with the anal stage of Freud's psychosexual development, where the child's experiences with toilet training can lead to outcomes that manifest as either excessive orderliness or messiness in adulthood, rather than shame, which is not directly linked to the oral stage.

Choice C reason : Bedwetting is not a condition associated with the oral stage of development. It is more related to the anal stage, where issues of control and independence are central, and bedwetting can be a manifestation of conflicts around toilet training.

Choice D reason : Overeating is a classic example of an oral stage fixation. According to Freud, if an individual's needs are not properly met during the oral stage (0–1 years), they may develop habits such as overeating or smoking to satisfy the residual need for oral stimulation.

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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 assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

Correct Answer is B

Explanation

A nurse is assisting with teaching a class about Freud's psychosexual stages. The nurse should reinforce that fixation at the oral stage of development can lead to which of the following conditions?

Correct Answer is D

Explanation

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