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 B
Explanation
Choice A reason : Identity refers to how individuals perceive themselves, including their beliefs, qualities, and expressions. It is the understanding of oneself as a distinct individual. In the context of the client's situation, while stress can impact one's sense of identity, the primary issue described does not directly relate to the client's identity but rather to their ability to fulfill expected roles.
Choice B reason : Role performance stressors arise when individuals feel they cannot meet the expectations associated with their social or work roles. In this case, the client is stressed due to the difficulty in balancing work responsibilities with the demands of caring for an ill family member. This indicates a conflict in role performance, as the client struggles to adequately fulfill the roles of both employee and caregiver.
Choice C reason : Body image pertains to one's perception of the physical self and the feelings associated with this perception. It includes how individuals view their own body and how they believe others perceive it. The client's stress does not stem from concerns about body image but from the pressures of their responsibilities.
Choice D reason : Self-esteem is the value one places on oneself, encompassing feelings of worthiness or unworthiness. It is influenced by various factors, including personal achievements and recognition from others. Although self-esteem can be affected by stress, the scenario provided specifically highlights the client's stress related to role fulfillment, not their self-worth.
Correct Answer is B
Explanation
The correct answer is: B. Identity vs. Role Confusion.
Choice A reason:
Autonomy vs. Shame and Doubt occurs in early childhood (ages 1-3). During this stage, children develop a sense of personal control over physical skills and a sense of independence. The focus is on developing autonomy, not on the social dynamics typical of adolescence.
Choice B reason:
Identity vs. Role Confusion is the stage that occurs during adolescence (ages 12-18). In this stage, teenagers explore their independence and develop a sense of self. They may rebel against caregivers and spend more time with peers as they form their identity and navigate social roles. This stage is crucial for developing a personal identity and a sense of direction in life.
Choice C reason:
Integrity vs. Despair occurs in late adulthood (ages 65 and older). This stage involves reflecting on one's life and either coming to terms with it or feeling a sense of despair over missed opportunities. It is not relevant to the experiences of an adolescent.
Choice D reason:
Trust vs. Mistrust is the first stage of Erikson's theory, occurring in infancy (birth to 18 months). This stage focuses on developing trust when caregivers provide reliability, care, and affection. A lack of this leads to mistrust. It does not pertain to the adolescent's developmental challenges.
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